HomeMy WebLinkAboutMortgage_Black (2) 0�`- STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
as ;1�Q FOR DEDUCTION FROM ASSESSED VALUATION County Township Year
-")�me'�",' State Form 43709(R14/1-20) Gibson 028 2020
r
"a•' Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: To be filed in person or by mail. B roadwayT/Patti - Si mpl i fi l e 12/10/2020 Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. IZI County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is
located on or before January 5 of the calendar year in which the pr erty taxes are first due and payable. 0 County Recorder
See reverse side for additional instructions and qualifications. (2_ '��( v
Applicant(owner or contract buyer-see restrictions on revert e side) '//��
age nu r•er
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Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applica t the sole
assessment date,current year assessment date,current year date of application legal or equi ble owner?
* 7',D n DO • D d es El No
If no,what is his/her exact share of interest? If owned with someo�other than spouse indicate^with whom
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If name on record is different than that of applicant,indicate below: Is terproperty in question:Annually Assessed
LJ Real Property 0 Annually Assessed
Mobile Home(IC 6-1.1-7)
Narle of mortgagee or .ontra set er
Address of mortgagee or contract eller(number and street,city,s ate,and ZIP code) • F I LED
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Name of assignee or other owner or holder of mortgage I Dec 10 2020
Address of assignee(number and street,city,state,and Z!P code)
GIBSON COUNTY AUDITOR CB
Does applicant own property in y If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other counon propert
in Indiana? El Yes No current year?for Xes 0 No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness 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 of County Auditor County Date(month,day,year)
CB G`son 12/10/2020
I/We certify under the penalty of perjury that the abov d foregoing information is true and correct and that the applicant is a resident of Indiana and
owner tract bu r of the aforementio ed grope on ate application is file
Signs nee 11 n e) Datel(mpnth, ay,year)
�� - Q-e ,l !�i_ae
F dent ad sofa plicanl(nu ber and street,city,sta- . d ZIP code)
Person authorized by duly executed Power of Attorney orb 6-1.1-12-0.7 t Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code)
The penalties for penury can include imprisonment uo to two and a half years and a fine not to exceed SS 10_000