Mortgage_Bradshaw (3) Mona STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
ae, • Coun Township Year
' e.,—=tt FOR DEDUCTION FROM ASSESSED VALUATION
State Fonn 43709(R12/6-14)
S ", Prescribed by Department of Local Government Finance I �
INSTRUCTIONS: ! ! ,.Fr
To be filed 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 sought.,pp pp
Must be filed or postmarked with the County Auditor or County Recorder of the county where the pre ky& 9 20 6❑ 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 County Auditor oft county
where the property is located during the twelve(12)months before March 31 of each year the dedu 'sl. , is 14404
See reverse side for additional instructions and qualifications.
CIBSON COUNTY AUDITOR
Applicant(owner or contract buyer-see striae reverse side)
side)
Taa,,;��2 Distri �f Key number/legal description Record number Pa ge nu{�^�/bgr
y -oy - Ail- 3oa - ooD . a66 - oao (p y7
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 Mardi 1.current year date of application legal or equitable owner?
SCO,O O O ❑ 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 •
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,d
Does applicant own property in any If ye rction been requested If yes,state amount of deduction
other county ,
in Indiana? Yes ❑No c- ❑Yes ❑No
A person is not entitled to this deductic
\R R y Jr contract indebtedness that is recorded in the county
recorder's office(including any home e �— L 1_ _1 L. ce)that is the basis for the deduction.
e l
S� 1000
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 property on date application is filed. •
XSigna"tur�e/s rullya Date(month,day,year)
Full resident address of applicant(number and street,cult state,and ZIP code)
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.
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