HomeMy WebLinkAboutMortgage_Campbell .tz4. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
County Township Year
' --e, FOR DEDUCTION FROM ASSESSED VALUATION \ �j
e'I �= State Form 43709 R13!10.15
.. ( ) ��
`����� Prescribed by Department of Local Government Finance •
� 6
INSTRUCTIONS: File Mark
To be filed in person or by mail. F. 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 the county where the property is r; 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.
Appli (owner contract uyer-see restrictions on a side)
Taxing st`,s l\ , K tmbr/I)gai edes1 p0o-3Oo� '1 - 0 v Recordbgr m PagenyYnpgr
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortga a Contract indebtedness unpaid Is the ap scant the sole
assessment date,current year assessment date,current year
ear date o i tion QQQ .legal or 'table owner?
L� g Yes ❑ No
If no,what is his1 her exact share of interest? If owned with s eene er an spcate with whom
If name on record is different than that of applicant,indicate below: 9 sr'e pro!:=. int .•n:Annually Assessed
n 1 P . I,ki r •- 11ttrrII AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of v or contrasell
b -jCI,� DEC 31 2019
Address of pRutgagee or contract-sager(number and street,city,state,and ZIP code)
Name of assignee or other owner or he i I
Drawer NO..• CA GIBBON COUNTY AUDITOR
Address of assignee(number and strei
(4,Q 3
Does applicant own property in any I Card 1 its deduction been requested If yes,state amount of deduction
other county Tarty for
in Indiana? ❑Yes ❑No it year? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the persons 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 , ip 20 20 20 ' 20' 20
Signature of CountyAudito 1_ �A County \ C � Date(month,
I/We certify under the penalty of perjury that the above and foregoing information is true iid correct and that the applicant is a resident of i diana and
• -r!contract buyer of the aforementioned property on date application is filed.
Sir 4! (ow is I e Date(month,day,year)
a dress of a lca umber and streetc- state and ZIP cod?) 12 3,
` " Sp 3oO Wes)
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 periury can include imprisonment UD to two and a half years and a fine not to exceed 510.000.