HomeMy WebLinkAboutMortgage_Birch eSTATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' '' r FOR DEDUCTION FROM ASSESSED VALUATION Cou Township Year
l_.'-' �-Y State Form 43709(R13110-15)
Presrnbed by Department of Local Government Finance
INSTRUCTIONS: `� Mark
To be filed in person or by mail. ' - Form filed with:
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 whet6i p%pert22&18 ❑ 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 properly is located during the twelve(12)months before Mardi 31 of each year the action" h[�
See reverse side for additional instructions and qualifications.
Ap$cant(owner or see resuicrio on sseside) GIBSONCOUNIYriuDiTOR
Taxing District iol number(a-Ana -6 DV . ?g 4-da3 Lil numberQ 43 number
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of l Is the applicant the sole
assessment data,amend year assessment date,anent year date of ap ication I legal or equitable owner?
3 6 ❑ yes ❑ No
If no,what is his/her exact share of interest? If owned with ne other than terse,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 0 AnnuallyAssessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller any r�
Address of mortgagee or contract seller(number and streeQI state,an Pcode))� _\``^'V"'►f""
L�����/wWr,
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
ededuction been requested If yes,state amount of deduction
otin Iebediiaanan? ❑Yes ❑No on
year?rty ❑Yes III 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 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 Lcontract b r of the aforementioned property on date application is filed. , ._ _
Sig re Date(month,day,year)
If nFug r e(7tI'\
d of number and sweet city,Yale,and ZIP code)
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of audwilied person (number and street 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.