HomeMy WebLinkAboutMortgage_Priar 0 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
it,.-,�--;• County Township Year
.( ; FOR DEDUCTION FROM ASSESSED VALUATION
f = State Fonn 43709(R13/10-15)
'4 tee" Prescribed by Department of Local Government FinanceF [- I E
.eis
'e Mark
INSTRUCTIONS:
To be filed in person or by mail. p� Form filed with:
Filing Dates: 1) Real Properly.Must be completed and dated in the calendar year for which the deduction iA014h1 3 2019
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 •,e)fir oft :1,��.
where the properly is located during the twelve(12)months before March 31 of eachh ar -4"' - II % r._.ht.See reverse side for additional instructions and qualifications. G�IiSON COUNTY AUDITOR
t
Applicant( er or contract buyer- e strlcdons on reverse side`ry1-'�-�'�j Q�J //� , A A l
T n District ember//'legal description K/J' �iui v Record number Page number
� 9 - 314 - 3oO _ bbd .79 I - 0a.'I ad/ 9 a? ( 3
A ssed 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 applicati n legal or equitable owner?
Sty Doti ❑ yes ❑ No
If no,what is his!her exact share of interest? If owned with someone other elan spouse,indicate with whom
if name on record is different than that of applicant,indicate below. I the operty in question:Annually Assessed
Weal Property 0 AnnuallyAssessed
• - Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller 5._ 3 •
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? )unt of deduction
other county
in Indiana? ❑Yes El No Drawer NO.. . .dl
A person is not entitled to this deduction unless the person has a balance on the persc riled in the county
recorder's office(including any home equity line of credit that is recorded in the county J rt..
COUNTYAUDII Card NO. 3`�,,
Deduction approved in the amount of.
20 20 20 20 - 20 ' 20• 20
Signature of County Auditor County Date(month,day,year)
f 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 aforementioned property on date application is filed.
Signature(owner's full name)/ Date(month,day,year)
1` "re/(o C CAI •i).,,,,,..:
Full resident address of applicant(number and street,city,state,and ZIP code)
a 74Z f /b-zs S #-4-figs-�-.,r �J 762f
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.