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. a. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou Township Year
'=_r� FOR DEDUCTION FROM ASSESSED VALUATION �_-
,�) State Form 43709(R73l10.15)
S Prescribed by Department of Local Government Finance
FILE l File Mark
INSTRUCTIONS:
FILE JAA��JJJJ tltltl
To be filed in person or by mail. Form filed with:
Filing Dater 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought
Must be filed orposlmadred with the County Auditor or County Recorder oethkeyating felt the property is urhty Auditor
located 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 county
where the properly is located during the twelve(12)months before Mardi 3 each edacfion is sought - -- -"
See reverse side for additional instructions and qualifications.
Appunnt(owner or•• •. r - see re, ••;• i• reverse side) CID130N COUNTY AUDITOR
T • D' ' Key chum /legal•- "ptian Record number Page number
i //� - 61(-l�19-/DaO00. 071-007 .2.o ) ea 3 3 3
Assessed value of real p••• ..of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date, t om` date of application legal or equitable owner?
�J OC ❑ Yes ❑ No
If no.what is his I 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
El Real Property ❑ Annually Assessed
Mobile Home(IC fr1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(num and street dry,state.and ZIP code) - '�"\v-L i �S ��S
Name of assignee or other owner or rider of mortgage r ..,,,,••........
Drawer i\
Address of assignee(number and street.city,state,and ZIP code) rj'--1`�
Does applicant own property in any If yes,what county? What Taxing District? J J ••••••• (deduction
Card 1\O. ............
other county
in Indiana? ❑Yes ❑No , —
A person is not entitled to this deduction unless the person has a balance on the person's. ._..,..uv in contract indebtedness 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//!1 20 20
Signature of•••.ty• •itor County ����v-i' / �/� Date(month,day year)
I e certify under the penalty of perjury that the a_bode 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.
re( name) Date(month,day,year)
Full resident address ofC4I and sheet dry,state.and ZIP code)
5/6 l.4 V. & 1.-r,S& / ln/ 4/7610
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 dry,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.