HomeMy WebLinkAboutMortgage_Lee ?e,. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS CountyTownship Year
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.�,�; FOR DEDUCTION FROM ASSESSED VALUATION //`
State Forth 43709(R13/10-15 q*0 n t /�) io\:20,9
Presatbed by Department of Local Government Finance ��lJ ���►JJJ��. ill%%% (k,(, .
INSTRUCTIONS: File Mark
To be filed in person or by mail. Form filed with:
Filing Date& 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 properly is County Auditor
located on or before January 5 of the immediately succeeding calendar year. ']\County Recorder
2) Mobile I 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
e'gside
for additiio(un�aall instructions and qualifications.
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Assessed value of real property as of Mortgage I Contact indebtedness unpaid as of Mortgage Contract indebtedness unpaid as f Is the ►Pm ra the sole
assessment data,current year assessment date,Current year date of �tiortg I �aO liftable or able owner?\C�j Yes ❑ No
If no,what is his/her exact share of interest? If armed with other than spouse,indicate with whom
If name on record is different than that of applicant indicate below. prupaty in question:Annually Assessed
Real Property 0 AnnuallyAssessed
• Mobile Hone(IC 61.1-7)
Name of mortgagee or contract seller , 01- 1 L
Address of mortgagee or contact seller(number andand street,city,state,a ZIP code) JAN
Name of assignee or other owner or holder of mortgage JA N y ZO+n
Address of assignee(number and abort,city,state,and ZIP code) 1j
GIBSnN Gnnrr-',,,,. �py���yt�
Does applicant own properly in any If yes,what county? What Taxing District? Has this deduction been re0Mf fl -&J r Uamount of deduction
countyother in ? ❑Yes ❑No . I /� I on property—----"---' ❑Yes ❑No ""r r llhl
A person is not entitled to this deductk 0L0 / 8 - 50 7 3 x contract indebtedness that is recorded in the county
recorder's office(including any home. Drawer NO ce)that is the basis for the deduction.
Deduction approved in the amount of .
Card NO. •
20_ 20 ' 20' 20
. —
Signature of County Auditor 1 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.
Sjnrreh er's full name) r� t_ l Date t ' day,CA yea -
�7(V 174 S I Ina E street
0o3do4 ZIP coden A+64O -1 1
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12 0.7-1 J •J 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.