HomeMy WebLinkAboutMortgage_Martin (13) j4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
` FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15) GIBSON
I:*I Prescribed by Department of Local Government Finance
GI6
INSTRUCTIONS: File Mark
To be filed in person or by mail. Fo m 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 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.
Applicant(owner or contract bu r-seee�r strictions on reverse side)
A—V) I NIA .
\alina Dist' t Key number/
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Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/C tr t indebtedness unpaid as of Is the a plicant the sole
assessment date,current year assessment date;current year date of app tics cco C legal or q ' ble owner?
(�,( (l/►urvl • Yes ❑ No
If no,what is his/her exact share of interest? If owned with someo a other thin spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is h property in question:Annually Assessed
VQ-I • •pe Annually Assessed
s ° v.s'e Home(IC 6-1.1-7)
Name of mortgagee or contract seller 11 ,
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
JUL 1 .0 202n
Name of assignee or other owr
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Address of assignee(number; ��
DrawerDrawerNO P)3-6. GIBSON COUNTY AUDITOR
I Does applicant own property it o this deduction been requested If yes,state amount of deduction
other county xoperty for
in Indiana? Ill Yes [_ Card N O. •ent year? ❑Yes ❑No
A person is not entitled to tt. ,rtgage or contract indebtedness that is recorded in the county
recorder's office(including;..., cy.my al IV(1r creorr mar 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 of un ditor County l Date(month,day,year)
I/We certify u der the penalty of perjury at the above and foregoing information is t and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
S• ure Hers f e // Date(month,day,year)
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nside t ress of applicant(numbe nd street,city,state,and ZIP ode)
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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 oeriury can include imprisonment up to two and a half years and a fine not to exceed S10.000.