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•^^n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
County Township Year
'x. " FOR DEDUCTION FROM ASSESSED VALUATION
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'�:-.• State Form 43709(R72/614)
' ; , Prescribed by Department of Local Government Finance I ILi
INSTRUCTIONS:
To be filed in person or by mail. P9cm filGp,�+�
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. S E r]� LU I�
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is LJ County Auditor
located on or before January 5 of the immediately succeeding calendar year. 0 cnrder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is during the twelve(12)months before March 31 of each year the deduction erg COUNTY AUDITOR
See rave - 5•e for additional instructions and qualifications. o�
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Appll • (o er or contractb r ee cif ortmverse side)
- buyer /��
ct ��-- Key n er I legs scrip ,/ Record number Page number
i y,. �ll� og-N--// .30/— a‘Jy Odd cJo/f Xa 2
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract' enbtedness unpaid as of Is the applicant the sole
Mardi 1,current year March 1,current year date of application / ) legal or equitable owner?
❑ 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 Is th property in question:Annually Assessed
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
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 ZIP code) �7 Z) j/ /I' -3-/
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amo.u(yy(t zof deduction
d
in other
ind county cnpmpyea? DI No
• .J c,J X15,
in Indian=o—❑Y¢s_❑No current year? ❑Yes
A persc -- `---.k-t=nce on the person's mortgage or contract indebtedness that is recorded in the county
roC0(dr Tom•m A N N S ed in the county recorders office)that is the basis for the deduction.
f/t��.L/" ;OUNTY AUDITOR .
� .�
Deduc 1
l5,.3 o a'1 20 20 20 20
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 afo -ntioned property on date application is filed.
Si.,-lure Coyne s..�. --- Date(month,day,year)
Fun r- �;7 - • applicant(number and street, code)
,.+�.. - pp ( city;state,and ZIP code
��(//T,� / aO6 E C1�U,Qcft St-
1v 1 Pe son auth•rized 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 310,000.
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