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inn STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
1 FOR DEDUCTION FROM ASSESSED VALUATION
'_. r: State Form 43709(R12/6-14) J ' '
Prescribed by Department of Local Government Finance
INSTRUCTIONS:
Ale Mark
To be filed in person or by mail. OCT 2 O 201" 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 county where the •perty is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. • song; ■ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County4�C{{{�ig • • •7
where the property is located during the twelve(12)months before March 31 of each yearVIV..� . • •- -'. .YitAU i • =
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on erne side)
1
Taxing Di�sbri Key .umber/legal description Record number Page number
At 2& — / / "- / ? ' /a 3 - 0°6 7 . 3 7 7 -0 1-4 a U nts 378 t
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 year date of application legal or equitable owner?
Tar o10 El Yes ID 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
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) I' r7 i e. r�.0 _ _
,r' z hr..7h N
Name of assignee or other owner or holder of mortgage 0 A rtr p.1-y..,¢/
Address o ssignee(number and street,city,state,and ZIP code)._ (S — 17 f irk
Pd-t .A-fa ( �L /o /" r
7
Does applicant own property in any If yes,what county? What Taxing District? Has this dedu P
other county on property fc- /O2 r 0/70.
in Indiana? ❑Yes ❑No current year? U Yes c_,.._ ,
A person is not entitled to this deduction unless the person has a balance 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 n�attureof 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 ntract buyer of the aforementio d property on date application is tiled.
A_Signatur ( efs full name) Date(month,day,year)•
A"lk Full resident address of applicant(rµin and street,city,state,and ZIP coded
Person authorized by duly executed Power of Attorney or by IC 1-11-12-0.7 / 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.