HomeMy WebLinkAboutMortgage_Emerson (9) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County 1 Township
I Year
84:- Zeg ; FOR DEDUCTION FROM ASSESSED VALUATION _te
Sta Farm 43709(R14/1-20) Gibson i 0 n 2020 i
.-.'. ..7,:•• Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS To be filed in person or by mail 1
. Form flied v.iith
Filing Date- Form tilt./St be completed and dated in the calendar year for which the deduction is sought 1
,
[11?-i Cott nty 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. [.........1 County Recorder
See reverse side for additional instructions and qualifications.
r Appucaot(J.4-ner o,contract -..er-see restrictions or reverse sitie) ,
1 Key number/legal description Record number I Pane:number „,.....--
2,7_ /6,e9 ....5-/ / 7
_.._ _ .._....._
AssesseO,value of r al property as of 1 tOortoage i Contract indebtednesS unpaid as of I Mortgage/Contract indebtedness:unpaid as of 1 Is the applicant the soie - 7
assessment datm urtent year assessment date current year I date of application legal or equ_ le owner?
I -z,3??/, (:)t) L„2:11-Yes E No
_._ ....____2
rIt rta.what is he tier exact snare of interest? I If omne:d with someone other than spouse,indicate with whom
i 1 1
if me onreO7)re ISOft:ere-A than that of applicant.indicate be:ow Is the perty in question:Annually Assessed --a
!----
Real Property EL Annually Assessed
. _
i , Mobile Home(IC 6-1.1-7)
. _ ___,
___________ _
!Name of mortgagee or.cortract s er '
Address of no gspec oT-corttract sal]er(ranter acd street my state.a,,1 ZIP codd)
l ,
_._....... __._
Hi-an, --c.,Tarcli -ala.--or othca ovener or holder of mortgage 40 --,
I rcir —Will
= rri I
c jr /
0 - ,
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!I rat Taxing District? I Has this deduct, een requested 'It yes,sG:teprn ount1Pdedue n-----------1
I, I on property for , _
L 1 err rent year? ' Yes Li No 1
ros,
/ i balance on the person's mortgage or co r t indebtedness that t recordethe county„
r recorded in the county recorder's office) th t i the basis for the deduCtion.
COUNTY AUDITOR
i 7 1
20 i 20 i 20
20 20
,
! 20 I 20 --1
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L . I ) 21_
.- • ,........,
Sgnature-o-1--o-cTirty Auri!tor ' —1-6c•TG;IL; Date(month. a year)
i/lAelki,(2,L ,Q1LA,70.1-k_vi.3_,_
I. _ 1
I/We certify under the penalty of perjury that above and foregoing information is true and correct and that the apphcant is a resident of Indiana and r
owner)contract buyer of the aforementione operty on date application is filed. 1
>_1 Sanatur tow, -;.;i--,:it,nam,e) - I Date(month day yar) -I
I .
.___.... __
!dent address of a„pclicaOtTOPrnribe;..f ed strset dty state and ZIP code)
41112 Ls> .J -0 ey- ,- 5, ).__P-o-77 Jell'767 Liic)
Person authorized by duly executed Poser of Attorney or bi IC 6-1 1-12-0 7 )1-)(:)ate(month.day year)
1 1
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Address of authorized person (number and street.city State.and ZIP coder ---1
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The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed S10,000.