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STATEMENT O MORTCAC= OR CONTRACT INJ_ 1 _DH=SS I Lour y` I'—Townsnlp I Year
"= ° FOR D=DUIC T ION FROM ASzo c zJ VALUATION
'..ei e] (Ri ) MA 312016
v.-c-• State Form 709 2/a-r-
i
\` Prescribed by Department of Local Government Finance
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INSTRUCTIONS: I 4 -4l
To be filed in person or by mail. - WM..led with:
Filing Dates: 1) Real:mpery:Must be completed and dated in the calendar year for which the deduction is sRd @SON COUR Y_AUDITOR
Must be tied or postmarked with the County Auditor or County Recorder of the county where the property is IJ County.Auditor
located on or before January 5 of the immediately succeeding calendar year. L I Couny Recorder
2) Mobile/M,anufactured Homes not assessed as Real Property:Must the with the County Auditor f the county
where the property is located during the Iweke(12)months before March 31 of each year the deduction is sought.
See reverse side for additional instructions and qualifications. •
I Applicant(owner or contact ouyer-see -hens cn reverse side)
Tan C_ , ti.�aa�.
text. r e_: lot:. /legal Eesuhpdon P>< l-415 53t, aL I Record number Page nu.-Set
-19-/ty ,5 -Ca) /� T49(n 237 �e ,za,a 1 hold f 1101
Assessed value of real property as of Mortgage/Contract indertedness unpaid as of Mortgage I Contract ineettedness unpaid as of Is the applicant tie sole
Mash 1,arrent year Mason 1.current year data of application legal or tete:rble owner?
/y6ji07/ Yes "0 No
I If no,what is his/her exa.share of interest? If owned with someone°trier than spouse,indicate with whom
If name on record is different man tat of applicant indicate below. Is the property in question:Annually Assessed
. p Real Property ❑ Annually Assessed
_ Mobile Home(10 51.1-7)
Name of mot.^ gee or a nta^t seller n"
1 Address of mortgagee ntact seller(nomoer a,d street.city.sore,and ZIP a.-) •
Name of assignee or other owner or holder of mortgage
•
Address of assignee(nuver and street city,sate,and ZIP core)
Does applicant own property in any If yes,wnat county? Taxing District? Has this deduction been requested If yes,state amount cf deduvdon
other county I on property for
in Indiana? ❑Yeti ❑No current year? ❑yes ❑No
A person is not endued to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded/in the rutty
recorder's office(including any home ecudy line of credit that is recorded in the county recorder's office)that is the basis for the deduction. .
I COUNTY AUDITOR
I Deduction approved in me amount of:
20 I - 20_ I . 20_ I 20 i 20 I 20 I 20
I Signature cf County Auditor • I Couny Date(month,day.year) '
•
I 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.
Signatu e(o nets lull name) I Date(month,day,year)
3 /�/� I
Fyn ies across licant(number and street,city,state,and ZIP code)
Mb S. 1D2 Pi7'u St �J/2nVQC/L /&J (176 ea
Person authorized by:idly executed Power of Anomey'or by IC 6-1.1-12-0.7 V ate(month,day yea)
Address of authorized person (number and street city,state,and ZIP rode)
The penalties for perjury can include imprisonment up to two and a half years and a the not to exceed 510,000.
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