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<#."V STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count Township Year
b ,,. FOR DEDUCTION FROM ASSESSED VALUATION
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tState Form 43709(R12/6-14)
� Prescribed by Department of Local Government Finance
INSTRUCTIONS: it
To be filed in person or by mail. F rn 6
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. //®A
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is• A" ❑ Coun #Wi
located on or before January 5 of the immediately succeeding calendar year. Aft' Q] Cq�ygt Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county `Ufa
where the property is located during the twelve(12)months before March 31 of each year the deduction is sougffl,
See reverse s'.a for additional instructions and qualifications. Oi8 � —
Appfinnt(. r contract buyer-see to ncd. s. reverse j SON COU ry
� n Record number Page nu'f r
es i . • .-00 O. 41.5 41% e 6.-•value of real property as of Mortgage/Contract indebtedness unpaid as of ortgage/Contract indebte• ess unpaid as of Is the applicant e sole
Marc,1,current year March 1,current year date of apyia;ion GO legal or equitable owner?
il(� de - ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone o her than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is a property in question:Annually Assessed
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee ntract seller (�/ip1�/`J'�`–'� ' flit
Address of mortgagee or coMFact seller(numbera d street,city,state,and ZIP code) ,jJ,
Name of assignee or other owner or holder of mortgage
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 deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? Yes No current year?
El El ❑
Yes ❑No
A person is not entitled to this deduction unless the person has a ba lance 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 County Date(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
4 l owner I contract buyer of the aforementioned property on date application is filed.
`W Sig tu)e(owner's full name), / Date(month,day,year)
ny �k P �n(�/ c y1 'UI�
A
Full resid6nt ad of applicant(numGe�dnd street,city,slate,and ZIP code)
20; E 1SQCPS-I- Skit fr )C(4 Strain L/, zN t?la 4?
Person authorized by duly executed Power of Attorney or by IC 6-1.1-1/0.7 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.