HomeMy WebLinkAboutMortgage_Cox (2) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County i Township Year I
FOR DEDUCTION FROM ASSESSED VALUATION _
(.i.5fitte; li State Form 43709(R14/1-20) Gibson owevi.50•11..e. 2020 I
-----.-- -- Prescribed by Department of Local Government Finance
-----a!tti---- 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 I
located on or before January 5 of the calendar year in which the property taxes are first due and payable, 0 County Recorder
See reverse side for additional instructions and qualifications.
[-Applicant(owner or contract buyer-see restrictions on reverse side)
Taxing --
l District Key number/legal description Record number -------- -
,
a6--(7-a i- VOOW_ 0-73-(2) ...), 7-0 2 \ _
[Assessed value of real property as of Mortgage i Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
I assessment date.current year assessmejal date.current year date of application legal or equitable owner?
..-- I-78., g 3S Fij..-YeS" LINO
-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 thelweperty in question:Annually Assessed
eat Property 1111 Annually Assessed
Mobile Home(IC 6-1.1-7)
_
Name of mortgagee or corltrct seller
kbC Le i- /HRof f-crre FILE1)---
Address of mortgagee or contract sel _r(namhear anr1 ctr , in ,,,,,,--,,a-,--.,„.
-----
Name of assignee or other owne DEC 0 7 2021
Address of nassignee(number air
amount_
Drawer NO
_
Yh,eluezi a..div_41,;n1*/
amount of deduction
Does applicant own property in a ..,! Tii-riaty EMPAMailattieYtondUtitiVECERstate in ir,e,r1icatanuan?ty oyes cl ii,
Card NO. ..,. 2.P----7) reronryeertrf?or F-1 Yes
El No
A person is not entitled to this ortgage or contract indebtedness that is recorded in the county
recorder's office(including an, , , „„.. ,,,L41 ocy i ctAltder's office)that is the basis for the deduction.
I COUNTY AUDITOR
Deduction approved in the amount of.
20 _ 20
1. 20
20 20 20 20
Signature of County Audito4 "k/av", ..----" County r Date(month.day year)
,--) -7
7-1/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.
Signature(owner's full name) Date(month.day year)
-12--`---,7--,. - I- -e i2,-1 -z_ I
Full resident address of applicant(number and street.city state.and ZIP code)
gi I 1 A) MQ-tn '14 00.)&15c):(Lk zr N -,--ricou_S .1
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$/0,000.