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•n.� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County I Township I Year
(a_ ! FOR DEDUCTION FROM ASSESSED VALUATION I$I
'it/ Sate Form 43709(R12/6-14) / LED
a Prescribed by Department of Local Government Finance Y JL AAA LL
INSTRUCTIONS: 1r. File Mark
To be filed in person or by mail. APR.0 4 20 16 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 coy , wbe -I he •.••_• 's County Auditor
located on or before January 5 of the immediately succeeding calendar year. I. , 7ptRji, I County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file Ogg::. f tat,i ,: r r.(ifp,
where the property is located during the twelve(12)months before March,i1.3 each year e •edu tfott sht.
See reverse side fob a tional instructions and u ifications.
Applicant(owner or 1 o c bwer-see,restrictions'n s side)lD II
-I Ta•'District �' I Key number/Legal esscriip',ioo Record number Pa a number
J fl�`'(e) 61 - 1a-o 3 -Jai -oa/.3aa-pad II/[/ ( �(,r/�/
Assessed value of real ry as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant e sole
March 1,current year March 1,current yea date of application legal or equitable owner?
I 000 ❑ 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 C /'1
Address of mortgagee or contract seller(number and street,city,state,and �dZIZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code)
-- ...._l.lf VP-S.A./hat county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
on property for r� I 1
current year? LI Yes ❑No
on has a balance on the person's mortgage or contract indebtedness that is recorded in the county
�'\3/ t that is recorded in the county recorder's office)that is the basis for the deduction.
Drawer NO U ti COUNTY AUDITOR
Card 1`O. T21 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/contract buyer of-th aforementioned property on date application is filed.
Sii�yature nets t A, Ls Date(month,day,year)
•
'T tEj si t address of a liiccann mbar and street,1 dt state,and code)
Rio of C4'jac
Person authorized by duly executed Power of Attorney or by I% -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.