HomeMy WebLinkAboutMortgage_Hiatt .�E�*• 4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS CountyTownship
�,�„ Year
di N. FOR DEDUCTION FROM ASSESSED VALUATION .� {�
it
-\ . 11' State Form 43709(R13/10-15) GIBSON �� V
Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
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 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(wiz-or contract buyer-sefiestn on reverse side)
-1h Ill (f^vi�'/]1� 26 'l 1.-12--Zo t1 CO3613---.U2.�.
Taxing District Key number/legal description Re rd nu ber Page er
26- 1-12 ?.0,•--0oo. g6'6 -Oz.g o d a �
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mo e/Contract indebted ss unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year d o legal or equitable owner?
� �0� ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned wit sIomeone oder than spouse,indicate with whom
Fil.,If name on record is different than that of applicant,indicate below: ` ] e !; in question:Annually Assessed
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)_
Name of mortgagee or ntract seller J U L 16 2020
Lift Ali— sue, Irk
Address of mortgagee or contract seller(number and street,dt state,and ZIP code)
444:-COga"-----'
Name of assignee or other owner or holder of mortgage OIBSON COUNTY AUDITOR
Address of assignee(number and street,city,state,and ZIP code) _ --
Does applicant own property in any If yes,what uction been requested If yes,state amount of deduction
other county O Dr ❑
in Indiana? ❑Yes ❑No (JJ' Yes ❑No
A person is not entitled to this deduction unles Drawer NO.... ...............r contract indebtedness that is recorded in the county
recorder's office(including any home equity lit ;e)that is the basis for the deduction.
Deduction approved in the amount of: Card N O. ....................
20 0 I I zU 20 20
Signature of County Au r County Date(month,day,yea
n 0 .
1/We certify under a penalty o perjury at the abo•- . d foregoing information is tru and correct and that the applicant is a resident of Indiana and
owner/ ontract buyer of the forementioned property on date application is filed.
Signatur ers II name) Date(m nth,day,year)
2 io( zola
Full r es ppli number a d street,city,state,and ZIP code)
son 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.