HomeMy WebLinkAboutMortgage_Gooch STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
'"s FOR DEDUCTION FROM ASSESSED VALUATION
,• State Form 43709(Etta 1i615) A;\,SO,n P.t zo )q
v Prescrbed by Department of Local Government Finance J YI
INSTRUCTIONS: I O �I "rC File Mark
To be filed in person or by mail. y.J �� 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 where the property is County Auditor
located on or before January 5 of the immediately succeeding calendar year. 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 March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant(owner or contact buyer-see restrictions on reverse side)
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T1 gajo yll1.I0'V'i .QQS� /'7 I O _ �oo- t O LI • 1 `�"'_Val description Ramd rumiher Page number
Assessed value of real property as of Mortgage/Caram.t indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment data,anent year assessment date,current year date of application Ctq legal or equitable owner?
105
44 ' ----- , ❑ yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other qi&spouse,indicate with whom
If name on record is different than that of applicant indicate below. Is the property in question:Annually Assessed
❑ RealPpty 0 Annually Assessed
• ,� Noble Home(IC 6,.,-7)
N_ aqm of mortgagee.aQco,.n.,tr\it)seller,
I �� .
Addlesst !Jg1•_ oor nta ( " /b
Address of mortgagee or contract seller(number and sleet city,state.and ZIP code)
✓Afy?82019
Name of assignee or other owner or bottler of mortgage
Address of assignee(number and sleet city,state,and ZIP code) aS
Gf ON CaUNry
Does applicant own property in any If yes,what county? what Taxing District? Has this deduction been requested If yes,stat&dentcf deduction
Indiana?other in ry ❑Yes El No currpro ent on year+?for ❑Yes ❑No Li'?
A person is not entitled to this deduction unless the person lies 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 I contract buyer of the aforementioned property on date application is filed.
S" natdre(owners fun name) (month, y,year)
10 ept ad of a�ti4an dum suet ,style. Z{Pogd( v n� �� 1 p 1 Q-1LV.
Person authorized by duly/executed Power of Attorney or by IC G1.1-122--0✓.7 r `-1 Date(month,day,year)
Address of authorized person (number and street city,state,and VP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.