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(2,_,:-,,,i STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou Township Year
f` r" FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13(10-15)
S� Prescribed by Department of Local Government Finance —;V .
INSTRUCTIONS: - + d- .,
75 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 A
Must be filed orposbnarked with the County Auditor or County Recorder of the county where the property/s U G 1 00�uniy Auditor
boated 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 of the cou
where the property is located during the twelve(12)months before March 31 of each year the deduction is -::1. .Irgjlr
See reverse side for additional instructions and qualifications.
fIRSOti COUNTY / UDITOR J owneror a•, - -seerstrictionsWIreverseside)
_ v. • ,
Taxing D' Key number/legal desert./ Pm Record number Page number
/ 7 . 6t _ yao - coo . 6, 78- 0A / /6 30107
,assessed vadhe real of e/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment current y assessment date,arrrent year date of application legal or equitable owner?
/02 / 67 0a ❑ 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 belovr. 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 setter(number and street thy,state.and ZIP code) _. --—
Name of assignee or other owner or holder of mortgage ` , _ tfI�if�� ga//'!1 C
Address of assignee(number and street,city,state,and ZIP code) 1\V)-{�� f"�11�n�n/tiv�l /1 •
Doer applicant own property in any It yes,what county? What Taring District? j ` int of deduction
In Indiana? ❑Yes ❑No I f a _3 0Q�"
A person is not entitled to Mis deduction unless the person has a balance on the pets l•r nroeotedness that is recorded in the county
recorder's office(including any home equity 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
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.
xSignature(ow full name) Date(month,day,year)
kY Full resident address of app5ant(number and street cub:staff,and LP code)
/\ 4970 A OooW C(7 Co 6,5
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,yea()
Address of autl'tatted person (number and street dty,state,and ZIP code)
The penalties for per)ury can include imprisonment up to two and a half years and a fine not to exceed 510,000.
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