HomeMy WebLinkAboutMortgage_Long (6) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
.'1`=, FOR DEDUCTION FROM ASSESSED VALUATION �-7��,
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State Form 43709(R14/1-20) RECEIVEgZ 2' j
-- Prescribed by Department of Local Government Finance
// File Mark
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INSTRUCTIONS: To be filed in person or by mail. / I esIcy I a_ c DEC 1 7 2021 Form filed with:
Filing Date: Form must be completed and dated in the calen 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.
Appj (owner or contract bus e restrictions on roverse ide
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Taxing District Ke ber/legal description Record number e
O2G c�-a3-1 —ldv�Utv�`��) y 2 � "
Assessed value of real property as of Mortgage/Contract indebtedness un aid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assesssnnnen dp,current year date of application legal or'' quitable owner?
Pes ❑No
If no,what is his/her exact share of interest?
t If owned with someone other than spouse,indicate with whom �-
If name on record is different than that of applicant,indicate below: i Is the property in question:Annually Assessed
eal Property Annually Assessed
/,/ �/�/// T1 T '''�■��'''''"""'''���' Mobile Home(IC 6-1.1-7)
Najd ofpmortgagee or contract ~--1�-..�-'"!'!i'^- ■ ■
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage JAN 05 2022
Address of assignee(number and street,city,state,and ZIP code) A Cit 2., c".2: ,j';
GIBSON COUNTY AUL, TOR
Does applicant own property in any If yes,what county? What Taxing District? Has this deductio bee requested If yes,state amount of deduction
th on property for
oin Indianaercou?nty ❑Yes ❑No current year? S 0 No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or o r 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) hat the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Aud(tgt'_ County So Dal( , r)
I/We certify under
�t(\\hee\penalty of perjury haSve and foregoing information is tr a d correct and that the applica t is r i aesideent of Indiana and
owner/contrac a of the aforementioned property on date application is filed.
Sig r"s / Date( nth a, ar)
Ar..a.,„,auD 1,_ Mlq7 /
F dent addre of scan number and street ity,state,and I de) / (r > Y �/ Z L CCJ,3
/�o/ 1� 1"r� C��,ve s/�K/
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$10,000.
RECEIPT FOR FILING STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
Name plicant .N ^ or contractrro,.
Date fil��h, ayjya2 P Amou tot inFJortgagee
s4 Taxing DistrictIGIP
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Key number/leg I desvipti�rr r7 l` / �' O� \ J� (' 2A �3 n
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Signature of County Auditor./C un Reco er..� Coun�tyy� Data((loath,
day
ear) s; Q
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