HomeMy WebLinkAboutMortgage_Smith (21) t o STATEMENT OF MORTGAGE OR CONTRACT INDEBT, S � unty Township Year_
_a FOR DEDUCTION FROM ASSESSED VALUATION ga
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State Form a3709(R73/70.75) 11. is0n White RNer Township 2019
Prescribed by Department of Local Government Finance
INSTRUCTIONS: JUL 2 3 2019 File Mark
To be filed in person or by mail. 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 th ounty a perry is • County Auditor
located on or before January 5 of the immediately succeeding calendar ye ❑ County Recorder
2) Mobile/Man act red Homes not assessed as
Real Property:Mustafj(g w 9 p(tgl y)et gyuntyg
where the roe is located duringthe twelve 12 months before Ma ftht3 e r e derdOctlo'tf sought.
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Clinton J. & Serena D. Smith
Taxing District Key number/legal description Record nulaer Page number
Patoka Twnshp 26-11-14-300-003.185-027 1A$
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
$100,000 p Yes ❑ No
If 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 applicant,indicate below: Is the property in question:Annually Assessed
❑� Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
First National Bank of Carmi
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested It yes,state amount of deduction
other county on property for
in Indiana? ❑Yes No current year? 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
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)
SA t mJl -y- Gibson 7/23/2019
I 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.
Signature(owners full name) Date(month,day,year)
—T_ 07/23/2019
Full resident address of applicant(number and street,city,state,and ZIP code)
2191 W 100 S, Princeton, IN 47670
Person authorized by duly executed Power 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 perjury can include imprisonment up to two and a half years and a fine not to exceed S10,000.
RECEIPT FOR FILING STATEMENT OF MORTGAGE OR CONTRACT IDEBTE LED
seller
of applicant Name of mortgagee or contract seller
Clinton J. & Serena D. Smith First National Bank of Carmi
Date fled(month,day,year) Amount of indebtedness Taxing District
07/23/19 S100,000 Patoka Townslf(9L 2.3 2019
Key number/legal description
26-11-14-300-003.185-027
Signature of County Auditor/County Recorder County Date
3A:r,ru:tS f2. Gibson G1gti 2959INTY AUDITOR