HomeMy WebLinkAboutMortgage_Moser STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
' '`:'* FOR DEDUCTION FROM ASSESSED VALUATION
" `' ( State Fonn 43709(R13/10-15 G ��1(�
*% ,,, S 1/4,30;1n .2-01C
, Prescribed by Department of Local Government Finance '
INSTRUCTIONS: ?\I) • File Mark
To be filed in person or by mail. - F rm ed 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 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.
pliant(owrr or contra�t�uyer-see restrictions on reverse side)
i 'd +1Y 11(\,ll�c p`TeatKey number/legal description Record nu P e nu ber
o '
le) IQ- 20-06-100-00I . B3$-o 0 1 250 -411
Assessetrlplue of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessmentdate,current year assessment date,current year da appli n 0 11 CD legal o eq ' ble owner?
1188 — . Yes El No
If no,what is his/her exact share of interest? If owned witssomeone other than pouse,indicate with whom
If name on record is different than that of applicant,indicate below: I e property in question:Annually Assessed
_■» - ..-, i, 7 I. -',..,ally
• i •Ole Home(IC 6-1.1 7)
Name of mortg or contract sell.krj l') i '
Address of m rtga a or contract seller(number and street ci(y,state,and ZIP code) DEC 2 ® 20 9
Name of assignee or other owner or holder of mortgage qJ
Address of assignee(number and street city,state,and ZIP c Drawer �t O �O I
f' GIBBON COUNTY AUDITOR
Does
county applicant own property in any If yes,what county? Card i-d �t O.. t .3 been requested If yes,state amount of deduction
otherin Indiana? ❑Yes 0 No I 3 000. c'—') I Yes ❑No
A person is not entitled to this deduction unless the pen , — tract indebtedness that is recorded in the county
recorder's office(including any home equity line of cred , et is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20 20' 20
Signature of County A for Coun Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information i ue 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.
Si ature(owner's full name) Date month,day,year)
C A�ti.G( It Ivy.�.e.... Z —2 d—��)
• •
Fyn resiAent address of applicant(number and street c state,and ZIP code) vi....4_t(t
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 perfury can include imprisonment Ile to two and a half years and a fine not to exceed$10,000.