HomeMy WebLinkAboutMortgage_Blacklock STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
..fit;.; FOR DEDUCTION FROM ASSESSED VALUATION n
Mk r1' _ State Form 43709(R13 110-15) Q\�J� , * C-
`% Prescribed by Department of Local Government Finance
INSTRUCTIONS:
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. (J County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the properly 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.
Applicant(pwsgror contractpurr-see restr'ctions on rev rse s'e)
3an'ies , �1ac.k1ock .
Taxin District umber//legal desscrip" j� (✓� ? (� Record number Page
Page number
�um r
�� � r �✓ �V_000. LA3_ 004 . 2�V �(_a•
Ass value of real property as of Mortgage/Contract indebtedness unpaid as of Mortg ge I Contract indebtedness unpaid as of Is the applicant the sole
assessmentdate,current year assessment date,current year dat appli tion q 11. legal or equ'table owner?
. 112�� 1` • Yes ❑ No
If no,what is his 1 her exact sham of interest? if owned with omeone other than spouse,indicate with whom
If name on record is differentthan that of applicant,indicate below: I e property in question:Annually Assessed
a
I:l•
z , ' P ■ AnnuallyAssessed
t
bile Home(IC 6-1.1-7)
/arblof mortg ee orEontract a ter I c4(.
I
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Address of mortgage otract seller(nur rb r and street;city,state,and ZIP code)
FEB 14 2020
Name of assignee or other owner or— .— -MD
Drawer NO:, - - A_-
.......... UIYJk RI . ►i.
Address of assignee(number ands �" GIBBON COUNTY AUDITOR
Does applicant own property in any Card �T • ••......... Has this deduction been requested if yes,state amount of deduction
other county '"'''''•• on property for
in Indiana? ❑Yes 0 No gg current year? ❑Yes ❑No
A person is not entitled to this d (� 0 0 — 5) 3 arson's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any unty recorder's office)that is the basis for the deduction.
JDITOR
Deduction approved in the amount or "^ r
20 11 I 20 dZ) 20 • 20 ' 20• 20
Signature of Cou •. r•itor County Date(m nth,da)r yeara
ire �w�l 14 L);11J��
I/We certify under the penalty of perjury that the above and foregoing information is tide and correct and that the applican •s a redident of Indiana and
owner I contract buyer of the afore entioned property on date application is filed.
Sig lure(own iI me) Datelo pr,day yea e D
•
ulf residen dd ss o applicant(number and street city,state,and ZIP code) L Il("„t L
Person authorized by duly executed Power of Attorney or by iC 6-1.1-12-17 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)
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