HomeMy WebLinkAboutMortgage_Burgess (3) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
••'40 State Form 43709(R14/1-20) Gibson Montgomery 2022
"+� '"✓ Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: To be filed in person or by maiL Form teed with
Filing Date: Form must be completed and dated in the
Michael & Dawn Burgess
Taxing District Key number/legal description Record number Page number
Montgomery 26-11-31-400-004.559-021 2022 4000
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?
$233,500 [ZIYes ❑Nd
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: Is the property in question:Annually Assessed
®Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller PILE
Liberty Federal Credit Union
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage DEE • 7 20�2
Address of assignee(number and street,city,state,and ZIP code) (ifQs'�y ' ' r A ,
CO&
Does applicant own property in any If yes,what county? What Taxing District? Has this dedL ttpfi /�-,ted If yes,state amount of deduction
other county Yes No an propertyyea
for
®Yes°-LJ No $ 3,000
in Indiana? ❑
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 20 20 20 20 20
Signature of County Auditor /� `�� p / � County Date(month,day,year)
*-\ -`.P)i.,t2 s__Q. 0 , �.( /Ck_ 7{- thg � Gibson I —.1—e�.'
I l%M. certify under the penalty of perjury that the above end forego in ation Is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signature(owner's full name) Date(month.day,year)
ca t s�9-x._. r .e.P,_--- 1a -al -Qca
Full resident address of applicant(number and street,city,state,and ZIP
4058 S 600 W, Owensville, IN 47665
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 S10,000.
RECEIPT FOR FILING STATEMENT OF MORTGAGE OR CONTRACT IN NESS
Name of applicant Name of mortgagee or cong el
Michael & Dawn Burgess Liberty Fed aI C � i� on
Date Ned(month,day,year) Amount of indebtedness ng District
�- _----1_,� $233,500 -0_,V) Montgomery
Key number I legal description L . ,('cam
26-11-31-400-004.559-021 oFL II
Signature of County Auditor/County R�a1� �J D
rder `� County .
\K\ � day,year)
` \1��r� � l� Gibson ‘ ,/ 1/�/,� , i ` Pv� — ��'