HomeMy WebLinkAboutMortgage_Coy (2) R•* STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
t •( -"4 FOR DEDUCTION FROM ASSESSED VALUATION
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r '%'' a•_ z State Form 43709(R13/10-15) 2018
"e4 Prescribed by Department of Local Government Finance File Mark
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INSTRUCTIONS: p5'�,
To be filled in person or by mail. FILED
Filing Dates: 1)Real Property: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 located on or before January 5 of the immediately succeeding calendar year. JUL 2 C1103y Auditor
2)Mobile/Manufactured Homes not assessed as Real Property: Must file with the County Auditor of the ❑ County Recorder
county where the property is located during the twelve(12)months before March 31 of each year the - _ -
deduction is sought. ,l/1���,
See reverse side for additional instructions and qualifications. A+a"^ '1
Applicant(owner or contract buyer-see restrictions on reverse side) G I BSON C O U N I I re.l r..,_.I O R
Derrick R. Coy and Kelli J. Coy
Taxing District Key number/legal description 26-23-18-100-002.544-024/12196 S 50 W, Record number Page number
Haubstadt, Indiana 47639 lb-03599
Assessed value of real property as of Mortgage/Contract Indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
$299,900.00 ❑Yes ❑ No
If no,what is his/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: Is thj�roperty in question: Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Heritage Federal Credit Union
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
5388 Old State Highway 66, Newburgh, IN 47629
Name of assignee or other owner or holder of mortgage
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
other county on property for deduction
in Indiana? ❑ Yes No current year? ❑ Yes ❑ No
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 in the amount of:
20 20 20 20 20_ 20_ 20
Signature of County Auditor County Date(month,day,year)
I/We certify under 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 ropert on date application is filed.
ature(ow er'S fu1 � CO Date(I 0 try, - ea I X
•
ull resident address o cant(number and street,city,state,and ZIP e)
12196 S 50., Haubstadt, IN 47639
Person authorized by duly executed Power of Attomey or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person(number and street.dry, 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.