HomeMy WebLinkAboutMortgage_Chambon STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
--442'\:. FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13110-15)
Prescribed by Department of Local Government Finance ��'''11 T
INSTRUCTIONS: _ q..d Taira
To be
INSTRUCTIONS:
or by mail. g
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 Rtyt}q{ uditor
located on or before January 5 of the immediately succeeding calendar year. i L L CO!��o 6Wty hecorder
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 Mardi 31 of each year the deduction is sought tl(
See reverse side for additional instructions and qualifications.
Applicantiwneror contract buyer- restrkt nil on reverse side)
^ -- GIBBON COUNTY.AUDITOR
51-Taxing District number/legal l�1 Inn Record n r e number
86- 17-01- Y60 - 003. 8'f3-0021 o Gtr? 7yS
Assessed value of real property as of Mortgage I Contact indebtedness unpaid as of Mortgage/Contrast indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of all,ort legal or equitable owner?
_ be 0 Yes 0 No
If no,what is his/her exact sham of interest? If owned with someone other than ii..indicate with whom
If name on record is different than that of applicant,indicate below-. Is the property in question:Annually Assessed
0 Real Property D Annually
on (Ised
• Mobile Home(IC 61.1-7)
Name of mortgagee or contract seller CI
Address of mortgagee or contract seaef(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage s
Address of assignee(number and street city.state,and ZIP code)
Does applicant am property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other in county property Yes 0 curntyr? Yes 0 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
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/contract buyer of the aforementioned property on date application is filed.
i near ( full name (month,day,yea
" FuC addressof:1....«/i(�nu`` • and street,dry, and Zip code) J , -r/ _ /-1�
scos I A kttie4 h/ Pouf Pr. /4'/ /e 1llIU/, L7L/ s
P authorized by duty executed Power of Attorney or by IC 6-1.1-12-al Date(month,day.year)
•
Address of authorized person (number and street city,state,and ZIP code)
The penalties for penury can include imprisonment up to 1Wd and a half years and a fine not to exceed$10,000.