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a. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
ift ',-
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
`- Prescribed by Department of Local Government Finance
INSTRUC77ONS: File Mark
To be filed in person or by mail. JU F47m fin:
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought �U
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. '■i -,,,rifer
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of th n dagngj j;
where the properly is located during the twelve(12)months before March 31 of each year the deductio �.0 . r AUDITOR
• reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
I n . T ja,..1 o sr& v `L
T District J Key number/legal description Record number Page number
t1..�J.eIa-l ) ac - a-a--1-2,o1 - orna_ 3k1'- Oaf a b t ol 0Vi_
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Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment cant,airier t year assessment date,current year date of application legal or equitable owner?
5 b 9 19 Lyres ❑ 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
[ f Property ID Annually Assessed
• ` Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller - -
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Address of nnngagee or contact sager(num and street _ ,,t11�
Name of assignee or other owner or holder otmortgage " \Vl G—'\r- Fl V, \
Address of assignee(number and street,city,state,and ZIP oodi .-.1\f Q-L
OWN, M
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otter• applicant own property in any If yes,what county? JI ls. 9.`le
In Indiana? ❑Yes 1��7', � O+ q V
A person is not entitled to this'deducion unless the pent O) ` 1 1� O -, I
recorders office(Including any home equity line of credit °` \ - a v 5 -7
`_ II ( 1
Deduction approved in the amount of c- — \
20 20 20
Signature of County Auditor
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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.
Signature(owwners full name) y Date(month,day,year)
irm.resident address of applicant(number and street city,store,and ZIP code)
3 2I. G Ie a-ol a. .. S- ' "P-.., e 0-n`- r---1\1 (-l-7 L 7 0
Person authorized by duly executed Power of Attorney or by IC 6-1.t-12-0.7 I Date(month,day,year)
Address of authorized person (number and sheet dty,state,and ZIP code)
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The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.