HomeMy WebLinkAboutMortgage_Lipscomb (2) S. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
r:% `7 FOR DEDUCTION FROM ASSESSED VALUATION
_�.i }'` State Form 43709(R13/10-15)
-- Prescribed by Department of Local Government Finance
INSTRUCTIONS: .. File Mark
To be filed in person or by mail. Form filed with:
Filing Dates: 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 immediately succeeding calendar year 0 County Recorder
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 qualifications. 1t,,
Applican
on
�1I(owper1 �ubuye�r pCCt us^e�sdeL S[Am(] 2 L Q
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UUM471 (`1T agau District ulLmh—k-s—/_�'l•I—�Io 1-001 E -00 V n1O;�`ner Page numbed .
Assessedvalue of as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness u pajd as of Is the apt sole
assessment date,current year assessment date,current year date of OJ legal or equ a owner?
ooOo - . Yes ❑ No
If no,what is his/her end share of interest? If owned with soon other thai sinne indicate with whom
It name on record is different than that of applicant,indicate belwr property in question:Annually Assessed
Name of mortgagee or contrail seller ` a K (- 45 3 V< '
Address of mortgagee or contrail seller(num and street ray,state.and ZIP code) AUG 31 2018
Name of assignee or other owner or holder of mortgage - -— /+'/
.Dra)YCI" No.. ... l� �(.W7o �.u,
Address of assignee(number and street city,state,and ZIP cods ^ GIBBON COUtlT`! AUDITOR
Does applicant own properly in any If yes,what county? Card \,O. / 9 7 .. esled If yes,state amount of deduction
other county ,4T 1 d
in Indiana? ❑Yes ❑No I {7 .. ....••••• I No
reocorder's office(including any hon is not entitled to this me equity line unless of credit _ ` �(U /yr c/Qd tedness for the deductio wed in the county
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 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 Riled.
yig e� I rr. v�� Dam sr>atlr�► yea•
J�`/F f1 address of applicant(nyeidAt
u � coodde�'), �A 1T'-w IY IlIJ' QQ
Person'VO ho C7 by duly �Paxka4Atto ecc�bykC 6-1.1-12-0.7 �J/ �� Date(month,day,year)
Address of authorized person (number and sheet 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.