Mortgage_Kenworthy (2) °c STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
'- =x 2 FOR DEDUCTION FROM ASSESSED VALUATION
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State Form 43709(R12/6-14)
'II •- Prescribed by Department of local Government Finance _
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INSTRUCTIONS: =
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. MAY R,
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is 7C Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ Coun Recorder
2) Mobile/Manufactured Homes not a - ed as Real Property:Must file with the County Auditor of the county
where the property is located during the -Ne(12)months before March 31 of each year the deductiordi•SOU9N
See reverse side additional instructions and qualifica .ns. o COUNTY AltOf7.
AdorApplicant •can on ct buyer-see restrirti son . - -side) OR
/',(1/si eca-
Taxi•. .is K umber/le -1 description Reco numbe Page number
�A, ;ieI -/ /?- A3 - coi. 0e3-6a2 poi& t 7396
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 March 1,current year date of app f tion legal or equitable owner?
d ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone o er than spouse,indicate with whom ,
If name on record is different than that of applicant,indicate below: Is the .operty in question:Annually Assessed
1! 'eat Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee ntract seller /f �
Tte—J"4:..xJ-i Q UJ7Li(.C.� 4 /
Address of mortgagee or contract seller(n r nd y,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)
rkws 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? Yes ❑No current year? ❑
El 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 office(including any home onuity line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
--COUNTY AUDITOR .
Deduction approved in the amount of: • -
Drawer 1\'0...
20 zo_ .•gO/'
20 20
Car _
Signature of County Auditor •• 1\O. .•• ••. .. 5•.• Date(month,day,year)
I/We certify under the penalty of po.,..., td correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property un .
,[ Signatu (o w�s na/rye) Date(month,day,year)
(� / �f Date(month,
it
K n sidaefifitaddress(f plicanl mbar and street,city,state,and ZIP code)
/3.2- t /0 ri /?2 tvts-m.; /c' 117!7 0
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 S10,000.