HomeMy WebLinkAboutMortgage_Campbell .MEa STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS CountyTownshi Year
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FOR DEDUCTION FROM ASSESSED VALUATION
R.-. "1'°. L/ State Form 43709(R14/1-20
„_ ....� > Gson 026 2021
\ ' a" ." Prescribed by Department of Local Government Finance
,er
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 taxes are first due and payable. ❑ County Recorder
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Campbell, Christine
Taxing District Key number/legal description Record nu, b�r Pagey�mber
!�-
026 26-19-18-101-001.151-026 .• O`L ,('}`-
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage Contract in btedness unpaid 6s of Is the applicant the sole
assessment date,current year assessment date,current year date of licati W legal or equitable owner?
( CO a-- . jlYes III No
If no,what is his/her exact share of interest? If owned with som one other than souse,indicate with whom
n.
If name on record is different than that of applicant,indicate below: I, itaj `, the property in question:Annually Assessed
eal Pro rty ❑Annually Assessed
).-' Mobile Home(IC 6-1.1-7)
Name of mortgagee [se JAN 12 2021 l
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage a........c-1
/
GIBSON t..._:...i`a 1 _ i O
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other counttl on property for
in Indiana? I ['Yes ❑No _ _ current year? ❑Yes III No
A person isl 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
r Signature of Cp u itor Count Date(month,day,year)
�� 1/12/2021
I/We certify under the penal of p 'ury tat abo and foregoing information is t e and correct and that the applicant is a resident of Indiana and
o r/contract buyer of the aforeme ' ed o on date application is filed.
Sig tub(o nets fu name) Date(moot,day,ye r)
c
- - -
Full resident address of applicant(nu er and street,c' ,state,and ZIP code)
909 Blackfoot Dr, Ft Branch, IN 47648
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)
T'---^^..,,,,.s-'aa,'ti rnninrbrrle.imorisonment up to two and a half years and a fine not to exceed$10,000.