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x°a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
a *S.,,1 FOR DEDUCTION FROM ASSESSED VALUATION •
;1 State Form 43709(R1216-14)
S -IV Prescribed by Department of Local Government Finance
INSTRUCTIONS: ile Mark
To be filed in person or by mail. Form flied with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is kpoiuglit..c1 ,ni5 rr..��
Must be filed or postmarked with the County Auditor or County Recorder of the county whdr�lhe ArdAeilf i L�.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 file with the CountyAu '{ r of the
where the property is located during the twelve(12)months before March 31 of each year the d ht. -See reverse side for additional instructions and qualifications. N rN Ot iNTY AUDITOR
Applicant(owner or contract buyer-seee(estriction�side)
Taxt istrict /U` Key umber l legal desmptio Recordiu1/45ger Pa e number
Assessed of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
March 1, nt year March 1,current year date of application legal or equitable owner?
So Soo CI Yes 0 N
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 yproperty in question:Annually Assessed
/ I Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
p/�� t
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Address of mortgagee or contract seller(number and street,city,stale,and ZIP code) '
Name of assignee or other owner or holder of mortgage _ - - --- -----
ellell
Address of assignee(number and street,city,state,and ZIP code) DEVc�.j A0
Does applicant own property in any If yes,what county? What Taxing District? "/-5- - p? 76 V rction
other county
in Indiana? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person': county
recorder's office(including any home equity line of credit that is recorded in the county re
COUNTY AUDITOI
Deduction approved in the amount of:
20 _ 20 20 20 20 20 20
Signature f county Auditor Coun Date(month,day,year)
/ 11411 sit n IA� 11)9t,) ,04.E /o -13-is
certify under the penalty of perjury that the above 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.
T Signatur owner's full name) n(� Date(month,day, ear)
p)(.lr of yn /,and Vet /0 // 4As�
Q Full resident address of applicant(number and street u state,and ZIP code) J
�� X15- Fr.5-1 'P r 00 , roc/ ,F'.�z/c°iiii , /h ki7a -vd
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$10,000.