Mortgage_Shoultz (2) rrA4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County I Township Year
./V11,-. FOR DEDUCTION FROM ASSESSED VALUATION LEI).. �,�-� F` State Form 43709(R12/G14) Igl1'
".-,.."':::4:-.." Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail. - MAY 2 .•1 '•win:
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 property al oun 'uditor
located on or before January 5 of the immediately succeeding calendar year. 1, ' 1111117 ( .unty Recorder
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the CountyAuditor J(i.: - r
where the property is located during the twelve(12)months before March 31 of each year the deduction is'u. .U - -
See reverse • e or additional instructions and qualifications.
Applicant(o er con ct buyer-seeres • 4s' reverses'--)
T °nyis'• / Key number/legal desaippir Record number Pag m /Assessed value of real p Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness un id as of Is the applicant the sole
Mardi 1,current year March 1,current year date of application l/ legal or equitable owner?
��( Q/� ❑ Yes ❑ No
If no what is his/her exact share of interest? If armed 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
.173 i3 a, •
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,city,state,and ZIP code)
4Z oC t CL Y/ / /O r, /�o6
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction ,
other county on property for _
in Indiana? ID Yes ❑No current year? ❑Yes ❑No
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 - -- ""''^'ro rccnrded in the county recorder's office)that is the basis for the deduction.
• Drawer NO )LINTY AUDITOR . I
Deduction
Card NO./51—(--/P4'84' S
20 20 20 20 20
Signature County Date(month,day,year)
I/We certify under the penalty of perjury that the above anu wicy..ing 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.
Si• -u -(owner's h )ci Date(month,day,year)
•
Full resident address of applicant(numbe d street,city,state,and ZIP Rd ,) —r /4--1
I 1797 N Old C'2-4-ershurr Rd Wihco-4-0n --L1\ (p1cp
Person authorized by duly executed Power of Attorney or by IC e�-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.