HomeMy WebLinkAboutMortgage_Lewis (13) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
r__.Nt •,\, FOR DEDUCTION FROM ASSESSED VALUATIONik , -�
•_,A`t J State Form 43709(R13/10-15) GIBSON �-y/) �.e11//y���
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"—.• N `Prescribed by Department of Local Government Finance 1
File Mark
INSTRUCTIONS:
To be filed in person or by mail. Form 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 County Auditor
located on or before January 5 of the immediately succeeding calendar year. County Recorder
2) Mobile/Manufactured Homes not assessed as Re roperty:Must file with the County Auditor of the county
where the property is located during the twelve(12)m nths before March 31 of each year the deduction is sought.
See reverse si for additional instru tions and qualifications.
Appli or con(act buyer- a strictions on reve side)/ all n `
,ACIL r
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Taxi is rict ../4.J.L ey nu b /legal description Record u ber Pa a num r
o?6' /A- '- xi 99.s- oaP 2� v �� , .
Assessed 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 appjlcation legal or equitable owner?
0 000 ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other Than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: — Is t property in question:Annually Assessed
Real Property- ❑_Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contracts Iler A
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address of mortgagee or contract seller ,'',�'''�(and street,city,state,and ZIP code)
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Name of assignee or other owner r r of mortga, P,y i,
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Address of assignee(number and scree ty,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been reques'eti'C fr 's 3# mou f deduction
other county on property fort'
in Indiana? ❑Yes ❑No current year? ❑Yes ❑No '-i(/,Dj�
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is record 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 20 20 20 20 20 20
Signature•�4unty[Auditor / County `Date(month,day,year)
I I We certify under th- 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.
Signs a(owner's full name) Date(month,day,year)
1
Full resident ad,r: s- applicant(number and street,city,statLe,and ZIP code)
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$10,000.
RECEIPT FOR FILING STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS�.
Na a applicant / ame of mortgagee°ncontra�ell r r Y r . )
Da 'led(mol day,ye.r) mo9rof indebtedness T ' D trot f^:
Key nu ber/legal description / ` tD
n7 -/ a,3- QD/ 99,sL2 o + 2�--0 �-3 .
Signature of ou Audited ounty der County ��t�' C.; V. d�year)
i.)-- �I GIBSON Q,7)414 _
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