HomeMy WebLinkAboutMortgage_Patrick Properties LLC Via, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
«' FOR DEDUCTION FROM ASSESSED VALUATION I /Vf
- '- State Form 43709(R13/70.15) ppp�t�\l � 1 Y\ ,��
`- Prescribed by Department of Local Government Finance _ {
INSTRUCTIONS: _ File Mark
To be filed in person or by mail. F nn filed with:
Filing Oates: 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 I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is boated during the twelve(12)months before Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications. /'
AppWant(artecQrcmraacI buyerr�reee ' ) A _t/- Luc
JP+ xa �h y\ Key rt�a I �^u- .'$/yvfyI _000 4 ^2J2 Remrd nun Page nut ob
Pssossed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness mWaid as of Is the applicant the sole
assessment date,current year assessment date,current year date WW :I.: W legal or equitable owner?
LX O b— ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with sb meoonene oNe/than spouse,indicate with whom
If name on record is different than that of applicant w.indicate below. Is the property in question:Annually Assessed
❑ Real Property 0 Annually Assessed
�/ •
at r� Mobile Home(IC 6-1.1-7)
Name of rtprtgaf mntratl i 1,\ I
I .
\ �(ry erAlle
Address of mortgagee or contract seller(number state )
Name of assignee or other owner or holder of mortgage \ " 1
p ..
C �
Address of assignee(number and street,dry,state,and ZIP:'•e 2019
Does applicant own property in any If yes,what county / . isbict? Has this deduction been requested If yes,state amount of deduction
on l�ndiaannan?7 ❑Yes ID No GIBBON COUNTY 1'.::^'TOR on y"-aryn ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
hbuader'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 my Auditor County • Date(month,day,year)
I IWe certify under the penalty of perjury that the above and foregoing information is true End correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned'�re property on date application is filed.
XSignature(owner's run aawe)—y-q-y Dakmwr[b,day,year)
Full
Date(month day yeton
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.