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1 a;, STATEMENT OF MORTGAGE OR CONTRACT INDEB S' t IS I Township I Year
r_i FOR DEDUCTION FROM ASSESSED VALUATION +
State Form 43709(R 12/6-14) )4 '
'' ' Prescribed by Deparunent of Local Government Finance
INSTRUCTIONS: MAR 1 8y 2015 File Mark
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the d-•action is ou•'
Must be filed or postmarked with the County Auditor or County Recorder of the •ti vi j c1t;111,••erty is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. .,.,..0 si ip1TOR ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property Must file yyit4,tta t�p1 of life county
where the property is located during the twelve(12)months before March M ch year the deduction is sought.
See reverse side for additional instructions and qualifications.
Applic t(owner or con t buyer—Get,resCK:i ns on reverses e)
V w 1. CQ�1Q 0
Toxin strict Cr ",number/legal description I Record number I Page number
Friv't ab-ia--as - do.3 -003330- /h &4d CIEs !U aolt5 /055
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of IgThe applicant the sole
March,n, nt;to March 1,current year date of appliya:iop O 006 I legal Cr equitable owner?
.�J7��� V /�- Cis CI No
If no,'.hat is his/her exact share of interest? If owned with sorneun.other Jan spouse.indicate with whom
If name on record is different than that of apolican4 indicate below. I Is the roperty in question:Annually Assessed
Is
Property ❑ Annually Assessed
1�//��//�� �/ /I (7 Mobile Home(IC 6-1.1-7)
Nan n e Or C.]f�islet r4 r • ..O 1 c,4Jte.
Address of rrmneagee or contract seller(num and street,city.stale. dZIP ode) O
5601 v\ < GiAcLvac -2h at* 4-Sa-a-7
Name of assignee or other owner or er of rnonga _
Address of assignee(number and street.city.state.and ZIP code)
Dees applicant own property in an ; yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes o current year? ❑Yes ❑No
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 I
Deduction approved in the amount of:
20 I 20 20 20 20 I 20 20
Signature of County Auditor I County Daze(month,day,year)
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
owner I contract buyer of the aforementioned properly on date application is filed.
ig cure(owner's full name) n I Date:(p{�o/nth.day,year)
Full residegt add f appli n�(numoer and so-ea city.state,an ZlP COde)' J —� thcc 7D
Person authorized by duty execututeedlr Power of Attorney or by IC 6-1.1-12-0.7 kr/•Y l [ Daze(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.