HomeMy WebLinkAboutMortgage_Ortiz (3) oa`r~ , STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
/.I._z`2k , FOR DEDUCTION FROM ASSESSED VALUATION
" t i l: State Form 43709 )
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m Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: To be filed in person or by mail.
Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. 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 property
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Taxing District Key number/legal description Record number Page number
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Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the a pli ant the sole
assessment date,current year assessment date,current year date of application legal or 'table owner?
Yes ❑No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: a property in question:Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
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Address of mortgagee or contract seller(number and street,city,state,and ZIP code) Li ,,
, ,
Name of assignee or other owner or holder of mortgage •
DEC 312020
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? e9uctibn been requested If yes,state amount of deduction
other
annyda? GIBSON current rlYi9 J��'e Ft
❑No El Yes ❑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 A or CS ,.) County Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signatu wner's full name) Date(moqh,d year)
url ent address of_pa plicant(nu nd stree, ate,and ZIP code) ry fib
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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 perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.