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•^•4v STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE g�unty Township Year
•4_- , FOR DEDUCTION FROM ASSESSED VALUATION A- Y
' j State Form 43709(R12/614) p�/, 1✓
Prescribed by Department of Local Government Finance •
INSTRUCTIONS: R �� 2015 File Mark
To be filed in person or by mail. 0) Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction s 5. e .
Must be filed or postmarked with the County Auditor or County Recorder of the „ my vltliryjr ro s ,Li County Auditor
located on or before January 5 of the immediately succeeding calendar year. I �w X011
��yy A ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with th� rUt2or of the county
where the property is located during the twelve(12)months before March:• . h year the deduction is sought. •
See reverse side for additional instructions and qualifications.
Applicant(owner or •ntract buyer-see r• frictions n reverse side)
axing District Key number/legal description Record u r P e um er
on Z4-/7- d Li -x/e0 000 ,5'0 o ,c l f j
Assessed value of r I property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Mardi 1,current year March 1,current year date of application legal or equitable owner?
6000 ❑ Yes ❑ No
If no,what is his/her exact share of interest? I If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate Is the property in question:Annually Assessed
� `� ?teal Property ❑ Annually Assessed
j-..t l.x- t ^ Mobile Home(IC 6-1.1-7)
Name of mortgagee Wad seller • FC ( C C K
Address of mortgagee or contract seller(number and sin �`�R�' ,S I. I�5��
Name of assignee or other owner or holder of mortgage 15- 1X11 ` 5 �Y
Address of assignee(number and street,city,state,and 2 16
1� ���\1/47p ,
CJ �,Q�f�
Does applicant own property in any If yes,what county' I ' Guested If yes,state amount of deduction
other county
in Indiana? ❑Yeti ID No
' I _ , - ❑No
A person is not entitled to this deduction unless the I - ► debtedness that is recorded in the county
recorder's office(including any home equity line of c I , 3 basis for the deduction.
Deduction approved in the amount of:
20 20 20 I 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
owner/contract buyer of the aforementioned property on date application is filed.
Signature full name /l Date(month,day,year)
./�
Fu..resident address of applicant(number and street,city,state,and ZIP code)
S/69 S. 9�■ .0'!v6 6VAc - 5'766....v-
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 S 10,000.