HomeMy WebLinkAboutMortgage_Heavrin iaSTATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
, FOR DEDUCTION FROM ASSESSED VALUATION County Township Year
.- State Form 43709(R13/10-15) I`�./\ ? 1� C.J✓1 C1 .
Prescribed by Department of Local Government Finance ���VVV N 1 `�"'`1('
INSTRUCTIONS: • File Mark
lb be filed in person or by mait X 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 orposbnarlred 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 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 qualifications.id N /'y r� ,/�
Applicant(owner or con rtt °I7 �7) \9 L 1 fPS�`�`-' Y t• J
T g District ` Key number/legal descriorionrVJ� R Page number
Assessed value of property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpa' of Is the appppUlic nt the sole
assessment date,current year assessment date,current year date of�ppix`jO �O2ti legal or eq�tl�bla wvneR
'C,71,.(,{u,`�,V, J t/r--.AYes ❑ No
If no,what is his/her exact share of interest? If owned with ne other n sjouse • with whom
If name on record is different than that of applicant,indicate below. property in question:Annually Assessed
Real Property 0 AnnuallyAssessed
F1ome(IC fr1.1-7)
Name of mortgagee or contract seller
& Uri) c- FC.(Aj JLi
Address of mortgagee or contract seller(number and street,city,state,and ZIP e) '
ls
Name of assignee or other owner or holder of mortgage APR 20
a$� °, —
Address of ass
^� / GIBSON COUNTY AUDITOR
Does applicant OHO{� I District? Has this deduction been requested If yes,state amount of deduction
in other Drawer NO on Varied? ❑Yes 0 No
A person is nc a on the person's mortgage or contract indebtedness that is recorded in the county
recorder's ofTh • ?? I in the county recorder's office)that is the basis for the deduction.NO. > -4?.: .
IUNTY AUDITOR
Deduction approved in the amount of.
20_ 20 20 20 - 20 ' 20' 20
Signs of County rjuditor County • Date(month,day,ye
(*,,A Sml'il'1 u11- *
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/contract buyer of the of mentioned property on date application is filed.
Sign r (owner' gname) (month,day,ye
1.-1 .- Z y 11
Fug Vent dres��s-ioff applicant number street dty and ZIP code)
I�ras 2-e0 l y duly executed� m�Y�r n 72-0 ant MG10 Date(month,day,year)
1
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. .
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