HomeMy WebLinkAboutMortgage_Clem (2) STATEMENT OF MORTGAGE &TRACT_1NiBTEDNEsS •
Count y I Township
ear Y I
14iikili. FOR DEDUCTION FROM ASSESSED VALU 110N
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\:11460;:i State Form 43709(R14/1-20) Gibson
00 \-A 2020 i
-%--- •---,' Prescribed by Department of Local Dover ej Fi e 1
File Mark
INSTRUCTIONS: To be filed in person or by mail.
Form filed with:
Filing Date: Form must be completed and dated in the cale r y r wh h t cti is s t_
Must be filed or postmarked with the County Auditor or C nty ec de f u v roperty is County Auditor
located on or before January 5 of the calendar
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rmp., ,(ov.m. ont a Vrft&ise.e rfvt:es..cctionsCvwsMda)
Taxing District 12yc u,mber I legal_deA.r.ri4tioAk 00...,0 0 0 0 0,..._..0 0 ki Record number Page.number
0 OLk . I . - n 2-1 6..5 4 5
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the ap leant the sole
'assessment date.current year assessment date current year date of pile ,...--. legal or e able owner?
I 1 5'S 0 0 0 . Yes 0 No
If no,what is his/her exact share of interest? If owned with s rceone other tha‘spouse.indicate with whom --------
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If name on record is different than that of applicant,indicate bolo, I ,t - property in question:Annually Assessed ------
Tf;rope nnbuiaelly°Assessed
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1 H me(IC 6-1.1-7)
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Name of nnOrtgag or ntract se.II '
‘N-2. ----
1I Address of mortgagee or contract selle n mbar an !rect.city state.and ZIP code)
DEC 1 5 2021
iCe'i4.71UDITOR
r-k„,-„,-,of assignee or other owner or holder of mortgage
Y124C/44Ze-,. „—e2_,-.1./-
'-'A-rldress of assignee(nurn-bar and street.city,state and ZIP code) (ms-o-p, COUNTY
II
1 ._
ees apPricant own property in any If yes what county? What Taxing District? ----Has this deduction requested If yes,state amount of deduction
1 D
I other county on property for
I in Indiana? r-i Yes No current year? Yes 0 No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contr ct 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.
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COUNTY AUDITOR '
1:5;c:16ction approved in the amount of:
i 20 20
1( 3x21 20
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Signature of County Audito V CO unty 20 20 20
\1-11 nr() )
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I!We certif under the penalty of perjury that the above and foregoing information is and correct and that the applicant i a resient of Indiana and
1 . nor/contra buyer of the aforementioned property on date application is filed.
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Si•rnal.17 •ame) Oat ( o cl91, )
A 711 yeri
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I Full esident a •eass of applicant(number and street city state and ZIP code)
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I Person a: •••• ad by duly executed Power of Attorney or by IC 6-1.1-12-0 7 Date(month.day year)
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i Address of authorized person (number and street.city slate.and ZIP code.) 1
•—_____. - - ___