HomeMy WebLinkAboutMortgage_Clark (10) t"`-`T�3v. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
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3• > ' X FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R14/1-20) Gibson O 2022
Prescribed by Department of Local Government Finance
�pti 1\ RECEIVED
0- 11 yl/,e 1 File Mark
INSTRUCTIONS: To be filed in person or by mail. i AU�7 2022 Ur� Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. `'1 v�ounty Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property r�r
is located on or before January 5 of the calendar year in which the property taxes are first due and payable. LTJ County Recorder
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
John W. Clark
Taxing District, Key number/legal description Record number Page number
Patoka (ot)Yn 26-04-25-400-000.562-020/Parcel ID(s):26-04-25-400-000.562-020 ota",54.,2 i -
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 legs o equitable owner?
$0.00 $168,000.00 Yes ❑ 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 below: F T L T Real D s e propeProrty in question:perty Annually Annually Assessed
[s 1, ❑ Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
The First National Bank of Carmi AUG 1 0 2022
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Carmi, IL 62821
Name of assignee or other owner or holder of mortgage //,C-/LaK a '�Y�'�
GIBBON COUNTY AUDITOfs
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 be n requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes ❑ No current year? Yes ❑ No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or c n 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)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
ignature of County Auditor 20 y _ ` (� County Date( o th,day,year)
(f�`1/lI� � Gibson g 10 ZZ..
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant is a re 'de t of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
\ Signature(owner's full name) Date(month,d�aa a day,ye
11 resident a redtf ss of applicant(number and street,city,state,and ZIP code)
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 of applicant Name of mortgagee or contract seller
33
John W. Clark The First National Bank of Carmi S.-
fn
Date filed(moot da a r) Amount of indebtedness ja • . trict,� ^ n
1pj - $168,000.00 FIL a tC� - o m
Key number/le al d scription r�' N m
26-04-25-400-000.562-020/Parcel ID(s): 26-04-25-400-000.562-020 `--O U. 3 r 12- .
Signature of County Auditor/County Recorder AUG-_^ _ County 1 0 2022 Date lonth,day,year)
((I' Gibson 10(2,2-
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GIBBON COUNTY AUDtTO