HomeMy WebLinkAboutMortgage_Kermode (2) `= STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
r.
FOR DEDUCTION FROM ASSESSED VALUATION
�' State Form 43709(R13/10-15) z01 C1
Presathed by Department of Local Government Finance
INSTRUCTIONS: • File Mark
To be filed in person or by mail. Fo sled 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 unty Auditor
located on or before January 5 of the immediately succeeding calendar year. unty 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 Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Aprtictnti(evner or car�fract r_sCv a rseUdfid e)_L K e
rmaciti
Taxifl p( Key n'l, r/legal description Record number Page number
,,�/� tD-ko 2 -01-25• ikop - 000 • 549 - 020 2O16I lL\ccI _
Assessed value of real property as of jMortgage!Canaria indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appli ant the sole
assessment data,current year assessment date,current year date of application / legal or equ owner?
2,,I
fI ooD Yes 0 No
d no,what is his!her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of apprKad,indicate belwr. Is in question:Annually Assessed
Property ❑ Annually Assessed.
FIL " (IC�, , �
Name of mortgagee or _trait seller rsi
o /I�t )54ai, `+2- a/iC1
Add of mortgagee or contact seller(number and sore;city state,and ZIP code)
JUN202019
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code)
GIBSO�UNTY AUDIAUDI R
Does applicanta own property in a f yes,what county? What Taxing District? Has property
been requested If yes,state amount U deduction
in Indiana?ty ❑Yes No arrrent year?or ❑Yes El No
A person is not entitled to this deduction unless the person has a balance on the person's mmtgdge 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
5 of County Auditor •, //// County Date(month,day,year)
�OW. r C.t kti ( bsiyi, b .2D-1 9
1 l We certify under the penalty of perjury`pa/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 aforernention property on date application is flied.
XSig�ta Ire`.V!, fu8pame 1j2 Date(month,day,year)
Full r/esident address`ls`offf a t(numberl�lr+d - "a state,andZL�cod f) !c/1DJ� 1,, A ,, �� /' .f
lei 1 45 I � /tea r a. ! Id ) V L icka JA �T7 O
Person authorized by duly executed P r of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)
The penalties for penury can include imprisonment up to two and a half years and a fine not to exceed$10,000. ,we'Lli-� V I