HomeMy WebLinkAboutMortgage_Willis (4) CSTATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
�; FOR DEDUCTION FROM ASSESSED VALUATION
State Fonn 43709(R13/10-15)
- - Presalbed by Department of Local Government Finance
INSTRUCTIONS: Fri .E a_h
To be filed in person or by mail. r Filing Oaten 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 immediate&succeeding calendar year. DEC 1 '
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the CountyAuditor of the county �""$
b'Recorder
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 quaffications. )j�ur
Applicant a centred buyer-see restrictions on reverse side) Jw "�
D'A I I11S GIBSON COUNTY AUDITOR
T 0"
[�I l Key number legal description - 627 Record
ZZr�I B Page number
300 to
�a a Tw�sh (O i2-Dg 3oz 355
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of I Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessnecd data nvrcS or date of application /j- _ // legal or a owner?
'' I / 2e 000, R(�/I/D71$ /JwttJ Yes 0 No
If no,what is his I her exact share of interest? I ,J. r•r Downed with someonebther than spouse,indicate with whom
If name on record is afferent than that of applicant indicate below. Is the property in question:Annually A«ssed
✓--' -al Property 0 AnnualyAssessed
• MOWe Home(IC 6-1.1-7)
Name oF •rtgageaorconaact seer i/!c?5 P5 J
Address of •.gee or contract seller(number and abeeL city,state,and ZIP code)
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 a If yes,what county? what Taxing District? Has this deduction been requested If yes,state amount of deduction
other in Indiana? ❑Yes No current year?on properly for ❑Yes 0 No
A person is not whiled to this deduction unless the person has a balance on the person's mot gage 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 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 I contract buyer of the aforementioned property on date application is filed.
Signature(owners fun name) (mondr,day,year)
3114 h zidli,i, jz
XFull resident dress of applicant(number a and L city,state,and ZIP code)
/86 QirfPr l,Al? / Pt;1 «fan i V. y-7low0
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 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.