HomeMy WebLinkAboutMortgage_Phillips } STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
• FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
c2) Prescribed by Department of Loral Government Finance
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INSTRUCTIONS:
person F J)
To be filed in person ar by mail F fi
Filing Oates: 1) Real Properly.Must be completed and dated in 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 is ❑ County Auditor
located on or before January 5 of the irnmediatey succeeding calerdar year I UN 2(A ,Go)ttty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must fife with the County Auditor of the counly 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 qualifications.
Applicant tocep5r Myer-f'ee re • • on reverse side n .
�Vyl' `-- TyJ 3/i, GIBSON COUNTY AUDITOR
Taring D Key number/legal Record number Page number
Key t(oo-oo .Soto- Oa '? 20■ g 251s
Assessed value of real property as of Mortgage I 'indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,arrant year date of application /�' ,.\ legal or equitable owner?
• /3,5 /60 ❑ yes ❑ No
It no,what is his/her exact share of interest? If owned with someone other than spouse,militate with whom
If name on record is different than that of applicant indicate bereft. Is the property in question:Annually Assessed
❑ Real Property ❑ AnnuatyAssessed
Mobile Horan tic 6-1.1-7)
Name of mortgagee or contract seller
e ',1 r1yI1( —__ /D+
Address of mortgagee or contract seer(number and street cty ste,and ZIP code) Drawer NO �°1
Name of assignee or other owner or holder of mortgage 23—/s -
Card NO
Address of assignee(number and street city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes ❑No current year? ❑Yes ❑No
A person is not entailed to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorders 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 in the amount ot.
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 I contract buyer of the aforementioned property on date application is filed.
(ow Dare(month,day,year) ..ident address of applicant(number and street city,state,and ZIP code)
) 3 6a 3 lop l ) Rink nr-J -Al 217G7
Person authorized by duty executed Poorer of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year "-
Address of authorized person (number and street city,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.