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STATEMENT OF MORTGAGE OR CONTRACT IND T , --- t
Di Cou Township Year
t
l;w FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15) 1 r MS
�- Presorted by Department of Local Government France "Cl 1.1
INSTRUCTIONS: File Mark
lb be filed in person or by marl. -*IMP
Filing Dates: 1) Real Property.Must be I'- ' &o Ag�1t OR Form filed with:
completed and dated in the calendar year for which n- '-re.,• 0� yy--��--tt
Must be filed or postmarked with the County Auditor or County --•• .:-.II'P... where the property is �cvCounty 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 property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side) .
/67�.nmY cLLCrcm o
axing District Key number/legal description Record number Page number
a /93i- yak 000 76(o 09 ? co/� 373 FS
value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract Indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,anent year date of application legal or equitable owner?
da?V(00 ❑ 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 di ferent than that of applicant,indicate below. Is the property in question:Annually Assessed
-pSLycear Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller /5r - _ -_
f—e-d �.a ,,gin ••
Address of mortgagee or contact seller(number and street,city,state,and ZIP code) 0000 3 7 3 S
s ,GCCI /am -
Name of assignee or other owner or holder of mortgage i
Drawer. NO...................
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own in any If yes,what court What Taws District? I -••' ix seduction
PWan property m r �+ e Card \O. ....... _:._. ,.
other county c I - -
in Indiana? ❑Yes ❑No c..,,ei'year? LI Yes ❑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(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 1 contract.- -r of the aforementioned property on gate application is filed.
Signature • - $IN•:me) Date(month,day,year)
r �� - /G 2-/G
F I —Vent ad• — t •pfi ant(n 7 and street,city,state,and ZIP code)
9o/ r= Na- U Fr— H•14,t11r.4 nr I-C...• 4'2d3 5
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Data(month,day,year)
Address of authorized person (number and street dry,slate,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.