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, -STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
^a 1� ty Township Year
a FOR DEDUCTION FROM ASSESSED VALUATION
st State Form 43709
Department/6-14)
J Prescribed by Department of Local Government Finance A
INSTRUCTIONS: APR 8 2016 File Mark
To be tiled in person or by mail. Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sou t. `^
Must be filed or postmarked with the County Auditor or County Recorder of the c /nty w roperty is JJ County Auditor
located on or before January 5 of the immediately succeeding calendar year. `�.JOIQJI� TAR /(_J County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must tiles Icefi)J It IFYofbD�i ACUllnty
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought.
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see res''coons on reverse side)
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m
Taxing Dislriat
nib/ Key nu ,legal description V / Record number Page number
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Assessed value of real property as of Mortgage/Contract indebtedneg unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current year lnJ/�t date of application legal or equitable owner?
4/7a0d ❑ Yes 0 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
‘pReal Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
FTfC11
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage ---C A
177 Address of assignee(number and street,city,state,and ZIP code) kcc,6.5 I D
SµPit
Does applicant own property in any If yes,what county? What Taxing District? �, feduction
other county I r 1
in Indiana? ❑Yes ❑No I rp
A person is not entitled to this deduction unless the person has a balance on the person: the county
recorder's office(including any home equity line of credit that is recorded in the county re
COUNTY AUDITOF
Deduction approved in the amount of:
20 20 20 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 the aforementioned pro erty on date application is filed.
ionature(owner
Date(month,day,year)
J G,
Full resident address of applicant(number and street,city,state,and ZIP code)
-1.q 9 S oS..,ZV o q ' 24,2n r ! ' if 7G yr
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 510,000.