HomeMy WebLinkAboutMortgage_Davis (11) aa STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
ril FOR DEDUCTION FROM ASSESSED VALUATION
r :- State Form 43709(R13/10-15)
�-- Prescribed by Department of Local Government Financo
INSTRUCTIONS: • Id- Ma ri 1
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 posbnarked with the County Auditor or County Recorder of the county where the property is NO I] CN4 '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 sough • ram,'
See reverse side for additional instructions and qualifications. �.:. nil, Pr
Appficant Wiper or contract bumer see re onJWerseeside) - GIBSON COUNTY AUDITOR
Taxing DiYisstricct lI -s Key r!/11 ��..v alfi l; Record number Page number
r -309- 001. ?sq-oar
Assessed value of real property as of Mortgage/Contact indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year da of applicationequitable owner?
legal or equita owner?
le (1:,. ❑ Yes ❑ No
It 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 belay. Is the property in question:Annually Assessed
I- ❑.Real Property 0 AnnuallyAssessed
- - - _•. w,. e Fin me 0C G1.1-7)
Name of mortgagee or contract seller
2f\
Address of mortgagee or contract sefler(number and street,city,state,and ZIP code) D r a lSe r NO. .02 0 ( U
flame of assignee or other owner or holder of mortgage / I
Card NO. `'1 .$-c
Address of assignee(number and street city,state,and ZIP code)
Does applicant awn property in any If yes,what county? What Taxing District? Has this deduction been requested n yes,stare arrrwin'a w,,,,,,..,,, •
othe county ,-, on property for in Indiana? ❑Yes ID No currentyear? ❑Yes 0 No
A person is not erditled 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 recorders 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 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.
Si re( name) : Date(month,day,year)
jar/.�-C
Futl V address of apgixant�(number and street ajy,state,ppIP code)
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(!x)(/o S J: O rt l/\ l/�1x t/tIt)(XSt coy l`[ P
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 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 S10,000.