Mortgage_Phillips t41<0 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year I k FOR DEDUCTION FROM ASSESSED VALUATION a ; )
1 State Form 43709(R12/6-14) 1
c—' Prescribed by Department of Local Government Finance
1
INSTRUCTIONS: 1 1 File Mark
To be filed in person or by mail. MAY 1 2015 Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought.
Must be filed or postmarked with the County Auditor or County Recorder of the c unty where the property is County Auditor
located on or before January 5 of the immediately succeeding calendar year. County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must tile with t tq f the county
where the property is located during the twelve(12)months before MprAA) c£ 16A1Af MW®aught. -
See reverse side for additional instructions and qualifications.
Applicant(owner or frddcf buyer-see bfion e rse Si )
TQ/k, . all a..c pActitiw
Taxing District K number/le descn lion Record num r Page umber
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a8 OD 4 al � 1 �iKp
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current.yay �./� date of application legal or equitable owner?
/ O ❑ 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. Is the property in question:Annually Assessed
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller /J 1
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIF
Does applicant own property in any If yes,what county? 1-A\\ C l Q 020/equested If yes,state amount of deduction
other county
in Indiana? ❑Yes ❑NO /ire/6? ❑No
A person is not entitled to this deduction unless the p Card N O indebtedness that is recorded in the county
recorder's office(including any home equity line of cn he 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
owner I contract buyer of the aforementioned property on date application is filed.
Shure(owners ame) Date(month,day,year)
pull resident address of applicant(number and street,city,state,and ZIP code)
XV� 3367 S. 4/Z5 &,J., 0,ie...v.1.o//e i4 5' 765
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 510,000.