HomeMy WebLinkAboutMortgage_Lance ,nr, � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
,, '` FOR DEDUCTION FROM ASSESSED VALUATION
Fik, ;le:..:..1 State Form 43709(R14/1-20) RECEVED Gibson 0 n \ 2021
%e Prescribed by Department of Local Government Finance
INSTRUCTIONS:To be filed in person or by mail. 1,1Anj FEB 1 0
2021 File Mark
Form filed with:
Filing Date: Form 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 County Auditor
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)
JEREMY R.LANCE and KALI R.LANCE
Taxing DjstrrI` Key number/legal description r �-p Record number Page numb
CJir!)/ 26-11-31-300-004.258-021 2- -\1""31-300 - op 9 ,Zs D-t77L( X 2,\ 66
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or eequj' ble owner?
170,000.00 LS Yes LI 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: Is the property in question:Annually Assessed
[Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller ii Imo '
The First National Bank of Carmi
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
201 East Main Street,P.O.Box 70,Carmi,IL 62821 FEB 1 0 2021
Name of assignee or other owner or holder of mortgage •
tthAddress of assignee(number and street,city,state,and ZIP code) a. f1�L7'iSvna)
GIBSON COUNTY AUDITOR
Does applicant own property in any If yes,what county? What Taxing District? Has this deduct' n een requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes o current year? Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or co ract 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 A Date month ay, ear)
I/We certify under the penalty of perjury that the above and foregoing information is`tfue and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned pr perty on date a lic tion i filed.
Signature r.wner's ful name) Date(month,day,year)
, /r �� January 22,2021
Full r, .erg-ss• nt(n mberand street, ity,state,and ZIP de)
v:41 r Stalheim A •wensville,IN 47665
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
January 22,2021
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.
RECEIPT FOR FILIN TA E NT el t;•,GE OR CONTRACT INDEBTEDNESS
Name of applicant e of mortgage or contracts Ilerso.4 Ccu
JEREMY R.LANCE and KALI R.LANCE , IS+ � 'l ,
�J T
Date filed month ay, jearr)) Amount�f>Laabt�dAs�02 Taxing District pr, )
t�' !/�J�1 170,000.00 0�1 0
Keynumber/legal description
gy �'. � z, 2oz. - 66
26-11-31-300-004.258-021 GIBSON COUNTY AUDITOR ,v
Signature of Cou ty uditQ/Co my Re .rde County 1 S^ Date(month day,year)
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