HomeMy WebLinkAboutMortgage_Hawkins (2) p STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
E_v f ' FOR DEDUCTION FROM ASSESSED VALUATION
p- State Form 43769(p13ar m nt )
o T I1 , p
�-- Prescribed by Department of Local Government Finance 1 �,1F�J_ YpLN9
INSTRUCTIONS: File Mark
l be filed in person or by mail. n� "�'�1� (f1t��QQ Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the efir�urmm is saagac CountyAuditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where the properly is
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the ►.u ^'the countyID County Recorder
where the property is located during the twelve(12)months before March 31 of e.-• --tr./'?•/-%1.. ils t.
See reverse side . itional instructions /{ua/fific/atiionn"ss. . GIBSON OUNTY ' I
Applicant(own/$ see rCSY�'\ �nl x�.lJ!'W )t�Or-
�:. .. r:/J1 r(xAVI)I
Daaid Key nu Record number Page number
l tq Co, Ill I a -a`7-1 a3-cod.33�f-odd aria 390n
value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment data,current year assessrnerd dace,currenitam date of application legal or equitable owner?
0 Yes 0 No
If no,what is his I her exact share of interest? If owned with someone other than c(rvsn,indicate with whom
t name on record is different than that of applicant indicate belovr is the property in question:Annually Accrcend
❑ Real Property ❑ Annually Assessed
• /l Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller ti)
L,1/10tnW L
Address of mortgagee or contract seller(number and sheet city,state,and ZIP code)
Name of assignee or other owner or holder of mortgagr
Address of assignee(number and street city,stare,a
/1- �— .3 7o ,'V��
Does applicant own properly in any If yes,what c _J:E �+ requested If yes,state amount of deduction
Indiana?other in a ❑Yes ID No ryryrJ s El No
A person is not entitled to this deduction unless me,,..r_._ /}(N 4_r n,r ct indebtedness that is recorded in the county
recorder's office(including any home equity line of credit that rs re.,... is the basis for the deduction.
COUNTY AUtn w..
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 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.
nature(amehr9 name) Date(month,day,year)
»ll re/si�a of applicant nuum�shea(kiry,/siate,and ZIRcode) Jr)
76 7o
CMI.0
Person authorizedby duly executed Power Attorney or by IC 6-1.1-12-0.7-/ Date(month,day,year)
Address of authorized person (number and street city,sate,and ZIP code)
The penalties for perjury can include imprisonment up to two and a hat years and a fine not to exceed$10,000.. -