HomeMy WebLinkAboutMortgage_Ellis (7) O STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Finn 43709(R13 I 10.15)
Presorted by Department of Local Government Finance ,� :I MI
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INS7RUC77ONS: . - - : a,I -17,
It be filed in person or by mail. - Form filed with:
Filing Oates 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought uqAN ,I.Q,
Must be filed or postmarked with the CountyAudiitor or County Recorder of the county where the property is 4 406 County Auditor
located on or before January 5 of the immediately succeeding calendar year
2) M obde/Manufactured Homes not assessed as Real Properly:Must file with the County Auditor of the nty C° My Recorder
where the properly is located during the twelve(12)months before Mamh 31 of each year the ded
See reverse side for additional instructions and quali fications. GIBBON COUNTY AIIfIITOR
int owtaeror contract �see../W ors reverse side) � •
Taxing District '(C Key number/legal description( Record number Page number
&/l.4- � a& —oa - 58 -033 • coot . 3 / ,- o , & 03.0/ J� Sa, Ie
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,cement year date of ap•�'�' owner?
° �'` legal or equitable owne
V/ J o 0 0 Yes ❑ No
If no,what is his 1 her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below-. Finnerty in question:Annualy Assessed
Real• Property 0 A� (IC Assessed
Name of mortgagee or contract seller Al
Address of ncrtgagee or contract seller(number and street cdy,state,and ZIP code)
Name of assignee or other owner or holder of mortgage 1/ C* `e
Add of assignee(number and street cty,state,and ZIP code)„ 1 l•t S
Kr fro - 33 - / - /s 1a. os f% c •-31-a 0%.113
Does applicant awn property in any If yes,what county? What Taxing District? Has this k ., 1 O a O i
other in Indiana? ❑Yes ❑No currrent) ��11 p `0`�_ 1 '�
A person is not entitled to this deduction unless the person has a balance on the person's mortg: a'C� x 1 6
recorder's office(including any home equity line of credit that is recorded in the county recorder's Mime)mar u.,, .__ .
COUNTY AUDITOR
Deduction approved in the amount of -
20 20 20 20 20 20 20
Signature of County Auditor County - Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is fled.
\i ( /J �fua name) Date(month,day,year)
-�4 J2s! J2 i QD- 5:- S-/ I
\/ Ful1 ' address of appficant(number and city.state.and ZIP code)
n 131 f g a., N zl<Cib,- ) Li-7(, 1c
Person authorized by duly executed Power of Attomestdr by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street coy,state,and ZIP code)
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±r.n n deice rnr nethi can include imprisonment up to two and a hat years and a fine not to exceed$10,000. .