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HomeMy WebLinkAboutMortgage_Callis .0^4, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township ,I +�'�,y FOR FROM ASSESSED VALUATION - Year �' 26 2o-z-D ", ,(i, State Form 43709(R13/10-15) GIBBON 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'S of the immediately succeeding calendar year County Recorder 2) Mobile/Manufactured Homed 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 qr contract bu�vI restrictions on reverse side) Taxing Distil Key number/legal description Record number. P ge number On - 7GIct -kE-3(0z —000 \i6_Q�6 0 1 2_02as . _ Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/. ontract indebtedness Unpai of Is the applicant the sole • assessment date,current year assessment date;current year .. date of ap tio` ...solegal or quitable owner? t J Yes ❑ No If no,what is his/her exact share of interest? . If owned with some ne other thart'spouse,indicate with whom • If name on record is different than that of applicant,indicate below: I e property in question:Annually Assessed Real Property ❑ Annually Assessed • Mobile Home(IC 6-1.1-7) Name rtgagee or contr ct seller • �� ! Address of mortgagee or contract seller(number and street,city,state,and ZIP code , 1 Name of assignee or other owner or holder of mortgage . V , • • . • Address of assignee(number and street,city,state,and ZIP code) AIL ?j S'Lu20 / p d/v /� J/ hat Taxing District deduction been requested If yes,state amount of deduction l� 7N �� Lf�riggjelrf Yes ❑No �' 3 balan (►30).0 mortgage or contract indebtedness that.is recorded in the county / / it /'�' recordW he county recorders office)that is the basis for the deduction: L 1/f4 N U///c? �`�t 4 per, COUNTY•AUDITOR .. 05 h -5 Ql). 20 20 -. 20 20 Signature of County Auditor County Date(moot dgie glo 2,0 ( I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is residert of Indiana and owner/contract buyer of the aforementioned property on date application is filed. Signat a(owner's full name) Date(m n,/,2 ta.6 ojurf Full reside addre f a plicant(number and sire city, e,and ZIP code) ©` 06#1 s-� On-- Lid 6 qg . Person authorized by duly executed Power of R(torney 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.