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ii' . STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
'ff -- ! FOR DEDUCTION FROM ASSESSED VALUATION
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, 'r State Form 43709(R13110-15)
`- Prescribed by DepartrneM of Loral Government Finance nos
INSTRUCTIONS: ,de���"
lb be filed in person or by mail. Formrim
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought Al Ga
Must be filed or postmarked with the County Audrtor or County Recorder of the county where the property is unty Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county Coin der
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought.4. AUDITOR
See rave side for additional instructions and qualifications. (1M COUNTY A
AppGCe/ ( ter or contras buyer-seeron reJerse CIS 62f6ax
../ifc2e—T r I(er I Record number Page number
,r 41 oco/ � 3UO- aa�o• Oc7S-O� V i (v 3y3Y
= =•value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
- - t date,current year assessment date,current year date of a icatoa., legal or equitable owner?
/ ❑ 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 appll ant,indicate below Is property in question:Annually Assessed
Real Property ❑ AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller 6/27/7
Address of mortgagee or contract seller(number end street city, -,and ZIP code)
Name of assignee or otter owner or holder of mortgage DI"a11'C1' jNo,
Address of assignee(number and street,dry:state,and ZIP code)
Card
f\'O. .•• .
Wh
Does applicant own property in any If yes,what county? at Taxing District? Has ft •• .'' ' - i
other on pit /I
in Indiana? Yes 0 N anent rW.. '{"/57, Oa
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is arta,.,......_, unty
recorders 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)
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/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 Red.
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Signature(o r3 rug name) Date(month,day.year-
,)( Full resident address of appfxant(number and street sty,state.and ZIP code)
kJ /000 5 !-/au6S4ad+ , IN 4x7639
Person authorized by duly executed Power of Attorney or by IC 5-1.1-12-0.7 Date(month,day,yea4
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. _ _