HomeMy WebLinkAboutMortgage_Lashbrook (2) .�,¢ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
_';,;;a. FOR DEDUCTION FROM ASSESSED VALUATION
71. f2 State Form 43709(R13/10-15)
,,,,-le Prescribed by Department of Local
the property is County Auditor
located on or before January 5 of the immediately succeeding calendar year. - C. my Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of tht i unty 1 , _ ,
where the property is located during the twelve{12)months before March 31 of each year the deduc'tit">e+t.is s'1 fir- —
See reverse side for additional instructions and qualifications. G I B S O N COUNTY AUDITOR
Applicant neror contract bu er-see restrictions on reverse side)
J
T District Key number/legal description Record number Pa ber
/i�Lc.�-aa - I3 -ao - / 03 _ d00.4ES-ooS ply• 06"
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I 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?
1 02 Q Do 0 ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone oticer than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: the operty in question:Annually Assessed
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
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' —=""^' ' -''J'--`=�'-'`� "24' tate amount of deduction
other county .0 — 0 / 9 , 2
in Indiana? ❑Yes ❑No �" /9 c7
A person is not entitled to this deduction unless the person has a ba is recorded in the county
recorder's office(including any home equity line of credit that is recx Drawer NO .duction.
•
Deduction approved in the amount of.
Card NO.
20 20 20 20
Signature of ounty Auditor , / I�.uunty • Date(month,day,year)
I/We certify under the penalty of perjury that the above an oregoing 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.
�/Sin re(owner's full name) Date(month,day,year)
/� 1 C - \a-3D- 19
ull resident address of app icant(number and street,city,state,and ZIP code)el
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` �w S. C�11 l r \-CR r c i SC o f �'1�lr� 1
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 penury can include imprisonment uo to two and a half years and a fine not to exceed S10.000.