HomeMy WebLinkAboutMortgage_Abell ... STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Courtty,F T Year
Ac` :i FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: • Mg`ilelh n 4018
To be filed in person or by mail. Form filed with:
Filing Oates 1) Real Property Must be completed and dated to the calendar year for which the deduction is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property , o. ifelu4 unty Auditor
located on or before January 5 of the immediately succeeding calendar year. GIBBON CO Nag �rder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and quaffications.
Applicant(owner or contract buyer-see restri�bns on reverse side)
l9_X3C11Q r s .
rDistrict � Key /�desaip� Record number Page number
>r- � a 1 a -b-1 - L-1 o -O oo .F5-1-DA-g a o IC 1. 1-is
Assessed value of real property as d Mortgage I Connect indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessmerd date,current year assessment date,current year date of application legal or equitable owner?
—1 L Cola- Irles ❑ No
If no,what is his I her exact share of interest? J If owned with someone other than spouse,indicate with whom
If name on record is(Efferent than that of applicant,indicate below: Is the property in question:Annually Assessed
• Property 0 Annually Assessed
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Name of mortgagee or.•tract seller — _
S
am,. ��•
Add —of mortgagee or contact seller(number and sheet ray,state,zr
Drawer NO �Q
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code) Card NO I (RS—
/
' 1
Does applicant own property in any If yes,what county? 1M_. .__. _ :yes,state amount of deduction
other in Indiana?county ❑yes ❑No I aoenre year ❑yes. LJ No I
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR •
Deduction approved li 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 •n date . •t•lication is filed.
Signature(owner's ha/name) - • `A• l I Date(urtn th.day,)eat
resident address of applicant number and atY and code)
7g/ E. lljdtr r // Vy-bnC& Z)l1 . '1702-7
Person authorized by duty executed Power of Amomey or by IC e-1.1-12-0.7 1 Date(month,day.year)
_ -- - _ •
Address of authorized person (number and street ray,state.and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.