HomeMy WebLinkAboutMortgage_Burke (2) • STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township YearR` FOR DEDUCTION FROM ASSESSED VALUATION
'• �1 State Form 43709(R14/1-20) G 1 b saw Owenj/l Ile
Prescribed by Department of Local Government Finance
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. O'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.
Applicant(owner or contract buyer-see resttRctions on reverse side) _
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Taxing District Key number/legal desertition Record number Page number
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Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
/PO,OOO Lyres ❑No
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 b . IL Is the property in question:Annually Assessed
[g'leal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
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Address of mortgagee or contract seller(number and street,city,state,and ZIP code)'�{/,
Name of assignee or other owner or holder of mortgage `%I a. ilk
GIBSON COUNTY AUDITOR
Address of assignee(number and street,city,state,and ZIP code)
, y �tbyy a '- � = Has this deduction been requested If yes,state amount of deduction
on property for eS ❑No
❑Yes NO - current year?
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract 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.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 I 20 20 20 1 20 20
Signatur County Aud'or. County Date(month,day,year)
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Q z% C,b So n 1 f/o2 a-/ -a
I/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
own- /contract buyer of the of rementioned property on date application is filed.
' Minor
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Full sent
address of applican (number and street,city,state,and ZIP cod
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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.