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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS county Township Year
FOR DEDUCTION FROM ASSESSED VALUATION .
-. 'C= State Form 43709(R13/10-15) .. •
Presrnbed by Department of Local Government Finance J ,^�'J.9 g�..�
INSTRUCTIONS:
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To be filed in person or by mad. Farhh filed with:
Firm Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is so
Must be filed or postmarked with the CountyAuditor or County Recorder of the county where the pMpeityla. 20 6❑ minty 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 h - county County Recorder
where the property is located during the twelve(12)months before March 31 of each year t the fed ..4%t. ;•� . _.,,,I
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See reverse side for additional instructions and qualifications. GI BSON r QUNTY er
A Uba I U R •
.....a (owner or centrac/Wtyer- restrictions on re side)
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T. r...District Key number/legal description Record number Page number
Iv a) 2-b - / a —� loo - oo/. 93 V -o,t 7 a°ice `1 980
Assessed value d�as of Mortgage/Contract indebtedness unpaid as of - Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment d tie,anent year aam.,mod data,amend year data of application legal or equitable owner?
/ 3o oo() ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than yiuse,indicate with whom
It name on record is different than that of appfxant indicate below: Is the property in question:Annually Assessed
❑ Real Property ❑ 6-1.1-7)
Name of mortgagee or contract seller s/0-
Address of mortgagee or contract sew(number and street,city,state,and ZIP code)
Name of assignee or other owner or troller of mortgage ' �1 ��� "�C \W�?� O r �
fiAddress of asignee(number and street all:state,and ZIP code) F���1ti��r..�r C`lor� C�C W
T id F_ -A0 /. /Y8 Y 4r <- 434\3t{ ,pd o o1l, 8d
Does applicant own property in any If yes,what county? - What Ta,drg District? Has the 3- Re
iindia ? ❑Yes ❑No aonrmm- Yl a
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(induce-mg any home egirly free of aedt 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 Amato, 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 appficant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
t s:., ,-(owner's bill na ne) h/d( ✓ Date(month,day,year)
x r /V I-/
1 /Fu e--.ell address of applicant(number city, ,and ZIP code)
JC 2teo-f7 (1 -/ c�'oo d €,2,ire., )c"cc/i' .r Ste/ , �co 7F0
Person authorized by duty executed Power of Niamey or by IC 61.1-12-0"7 / Date(month,day,year)
Address of authorized person (number and street oily state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 510,000.