HomeMy WebLinkAboutMortgage_Leible (2) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION Li„ A �r�
State Form 43709(R13 f 10.15) `A S� � l 0 19
Presorted by Department of Local Government Finance 1
INSTRUCTIONS: File Mark
lb 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 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 immediately succeeding calendar year. ounty 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 Mang 31 of each year the deduction is sought
See reverse side for additional instnrctions and qualifications.
Ap9list a3t ner Or contractbuyer-see fib`on reverse ) Lb\t
Twin Key number/legal description Record number Pag number
Pt �w�tln 26-t9-t k- IOS -001 .tcl2— � . ') 0t8 �t.9-3"t_ .
Acmceed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid of Is the apppp nt the sole
assessment date,current year assessment date,current year date of pliauoon 0' legal or Sable owneR
p t (�S OOO rr'xYes ❑ No
If no,what is his/her exact share of interest? If owned with soMeone er than spouse,indicate with whom
if name on record is different than that of applicant,indicate below I3he property in question:Annually Assessed
Real Property 0 AnnuagyAssessed
II�� '°r�(IC�, ,
Name of mortgagee m corxYdci seller
l fio� )1 �-t e
Address of mortgagee or contract seer(number and atreel, te.and ZIP code) \1
.IAN 9 2019
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,anc '
() g 7 5 GIBSON COUNTY AUDITOR
other applicant own property in any If yes,what coon en requested If yes,state amount of deduction
in Indiana? ❑Yes ❑No f\1 'es ❑No
A person is not entriled to this deduction unless thr Drawer O let indebtedness that is recorded in the county
recorder's office(including any home equity fine o1 - is the basis for the deduction.
Deduction approved inthe amount of Card N O.
•
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 coned and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signature(owner's dui name) �� pp� Dale(month,day,year)
xwlXY I- 9-II .
Full resident address of applicant(number an arty,state,and P code)
7k82, S Anaee � � 9�— �►�6 4 8
Person authorized by duly executed Power of Attorney or I 0.1.1-12-0.7 - 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 510,000. .