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f, ,. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FILE FOR DEDUCTION FROM ASSESSED VALUATION ,/
egop St ate FOnn 43709(R13/10-15)
Prescribed by Department of Local Government Finance
File Mark
lb be led in person JUL 1 1 20i&rmhledwit:
lb be filed in person w by mail.
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 , sky rty is El County Auditor
located on or before January 5 of the immediately succeeding calendar year. � • gr?f7ji i ❑ County Recorder
2) were the property located during twelve(12)months Properly:fore March with 11 of each year the e •a'n s -.v.% t U D I TOR
year ,-, qt Y P
See reverse - for additional instnrctons and quali ations.
Applicant(• contact buyer- iiiir on re rue side)//
b�Q/I" Jr !/i Lj'ns
Tie / / '..- / description '/ / R numyer f u@Qe/
4-- CCL �� -/e-0,5' 17=00 �` .3o27- 6o1_7 ��fP `L,
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 date,current year assessment date,current year date of appr legal or equitable owner?
�6 ❑ yes 0 N
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(Efferent than that of applicant,indicate below. I th property in question:Annually Assessed
• I
Property ❑ Annually Assessed
///1 •. Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller C
Address of mortgagee or contact seller(number and street city,state,and DP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street ctA:state,and ZIP code)
Does applicant own property in any If yes,what county? what Taxing District? Has this deduction been requested If yes,state amount of deduction
NnIndiaannan? ❑Yes ❑No aaiirnnt property R ❑Yes 0 No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contact indebtedness that is recorded in the county
recorders office(induding any home equity line of credit that is recorded in the county recorders office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20 20 20
Signature of County Auditor County Date(month,day,year)
1/We certify under the of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner!contract b r of the a rementioned property on date application is filet
f Signature(owners full e) ; /'�i' `/7— 'Date(month,da year)
- iiG4ruK 1 1�.,e� 7— / /—
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Fug resident address of apprxant(nu and sheet dty,state,and ZIP code)
J 337?c _ -h ,c) H"-irCe. 7 .i.J /T�7o
Person authorized by duly executed Power of Attorney or by IC• 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$10,000.