HomeMy WebLinkAboutMortgage_Gray (6) 06rr"per STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS 4)N ship Year
.`••`_.-, 1,. FOR DEDUCTION FROM ASSESSED VALUATION ;j �'
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" 2/ State Form 43709(R14/1-20)
.- Prescribed by Department of Local Government Finance
,(I ,)Mark
INSTRUCTIONS: To be filed in person or by mail. N 0 V 1 2 (J !r1
orm filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. ounty Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where theerty i
located on or before January 5 of the calendar year in which the property taxes are first due and pW-
OCounty Recorder
GIBS( OUNTY A InITOR
See reverse side for additional instructions and qualifications.
Applicant(owner or co act,•r-see restrictions on r erse side) I
T x' District /ey number/I al descripti Record number Page number
et-004-) d 026, - // - /b - 3oO - °Oa -3 S ci.,D giz7 rao `kp s22I
Assessed value of real pro rty as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the a plic t the sole
assessment date,current year assessment date,current year date of application legal or q able owner?
5(v D D a Yes ❑No
If no,what is his/her exact share of interest? If owned with someone other spouse,indicate with whom
If name on record is different than that of applicant,indicate below: f she property in question:Annually Assessed
I Real Property [.Annually Assessed
Dile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) acab
Drawer NO
Name of assignee or other owner or holder of mortgage
Address of:assignee(number and street,city,state,and ZIP code)
,Card NO O'
Does applicant own property in any If yes,what county? What Taxing District? Has this deduc' n be requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes ❑No current year? Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contra ndebtedness that is recorded in 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 f County Auditor, County Date(month,day,year)
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.,
I/We certify under the penalty of perjury that the a ve and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned prop rty on date application is filed.
)C Signature(owner' Date(month,day,year)
VFull resident address of ap licant(number an street,city, toe,and ZIP code)
•Z g g Y 5o ,d � ' y-2 le 7 0
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.