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�5� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
y1' FOR DEDUCTION FROM ASSESSED VALUATION FIT yy��
,--' '° State Form 43709(R13!10.15) 9 C '�(
�% Prescribed by Department of Local Government Finance 3® _
INSTRUCTIONS: File Mark
To
be Med in person or by mail. AUG 16_ (.640 filed with:
Fling Dates: 1) Real Properly.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 pmpe is ❑ County 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 CountyAud tQr of th
where the property is located during the twelve(12)months before March 31 of each year the dettlbEM a E fiNTY H DUI I tilt
See reverse side for additional instructions and qualifications.
Appfiam(rnvnerorFOnaau buyer-see restrictions reverse side) L
Taxing District �1�)-1-��il �numb2r/1l/`7at,'_1 description Record number Page number
cr y ) act - IA-a1 - .O - o?3r), b-tn -43..T dole 3333
Assessed value of real property as of Mortgage!Contract indebtedness unpaid as of Mort gage!Contract'indebtedness unpaid as of Is the applicant the sole
assessment date,aurentyear nt date,current year date of application legal or equitable owner?
�i TS-1)Q b Co ID 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 belay __—_--_.I u..._____ ...__- ssessed
-c.,rCI uRA.hv:cy. Ab weed
e(IC 6r1.1-7)
Nam of mortgagee or contract seller ;A\QC.-- •
2,..,,h (1_,,VL Q 3 . r� i U 1
Address of mortgagee or contact seller(number and sheet city,state,and ZIP code) D 1'11Y C 1" t O...'^.. ...•.......
z\off loco °°--....-3...(3...3..........
Name of assignee or other owner or kidder of mortgage Curd \O. ..
Address of assignee(number and street,dry;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
other irt Indiana? ❑Yes El No wnen�current ❑Yes 0 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(inducting 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 t contract buyer of the aforementioned property on date application is filed.
Signature(ow name) ' / Date(month,day,year)
[_(e -�Jl/
Full resident address of appfxant number and street oily;state,and ZIP code) _
�(Q i I f0 - N- P SJ P,Wx1•aQm , /� 41670
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.