HomeMy WebLinkAboutMortgage_Richard (2) „....RA..a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
4, FOR DEDUCTION FROM ASSESSED VALUATION 4\4!t'Th1(
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5 State Form 43709(R14/1-20)
i`-ii_4 : Prescribed by Department of Local Govern r,tra4�Fipance
`' �/I ,'�-^`n_ F' Mark
INSTRUCTIONS: To be filed in person or by mai/."1 \ 6, `�^ ' ,� Form filed with:
Filing Date: Form must be completed and dated in the calend- _- • • -' • -- -'• cti is sought. %County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is ❑ County Recorder
located on or before January 5 of the calendar year in which the property taxes are first due and payable.
See reverse side for additional instructions and qualifications.
Applica 0 her or contract buyer-�@e reItions se sib /, ' / 9 // /�
Ta Disfr t GS(Ke `jsmber/legal description (�J(jr 7�C L'i//�/��C�� • / Record number Page number
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Assessed value of real prope as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the
owner?sole
assessment date,current year assessment date,current year date of a s licat � gequitable
*54 G/U° s ❑No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
F If name on record is different than that of applicant,indicate below:�/� s t
eapro pp;r; ■ nnuallyAnnually AssesseAssessedd
C J ///777 Mobile Home(IC 6-1.1-7)
Name of agee contracts �G / '/ APR 1-9 2022
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Ad s ortgagee or contract seller number and street,city,state,and ZIP code)
`)Zu,,,,z, a.. 1.46;z!..tt..,iu✓
Name of assignee or other owner or holder of mortgage GIBBON COUNTY AUDITOR
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deductio - een requested If yes,state amount of deduction
on property for Yes El No
inot Indiana?hercounty ❑Yes El No current year?
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or c 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)tha is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20
2 20 20 20 20 20
County Date( nth, n —
S' atu of C my Au r `r� � r u ,
/e � .9 .UIaSI�%� U._/` ���lll
/We certify under the penalty of perjury that the above and foregoing information is true d correct and that the applicant is a siden of Indiana and
owner/contract buyer of the aforementioned property on date application is filed. Date(month,day,year)
�/ Signature(owner's full name) Qk
n /� `5_ Zv-��_A •_ _e.v /�,� rf A Al WHO-1`)ei - -
Full resident address of ap leant(number and street,city,state,and ZIPrgojde) � -�
X9l9 5 Do GLipp L,�yk_P_ 't-'r I c=e-T6� / ZN' Date(month,day.year)
Person authorized by duly executds7Power of Attorney or by IC 6-1.1-12-0.7 I
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
r I Nam f_pl jgee or ll
Nam o pplicant u.J``
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Date ed(month, ,year) I Amount of indebtedness
P4I
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Key number/legal description AP 2q2
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Signat a of count yAuditoounty R r aYI.
.•nth ,ay,year)
-�' ✓� I C / J'JID ON COUNTY '4 g} �- ,1O/
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