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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
rye'. FOR DEDUCTION FROM ASSESSED VALUATION TOE'" I Year
State Foam 437 Depa l 1 nt o
Presrn'bed try Departrnent of L ocal Government Finance
To be flied C in person or by marl- DEC 21 2.016 File Mark
Fenn filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. �i
Must be filed or postmarked with the CountyAUddor or County Recorder of the county . •- - :ptt.:rigf.: /gE County Auditor
located on or before January 5 of the immediately succeeding calendar year. Y AUpCC U ❑ County Recorder
2) Mobile I Manufactured Homes not assessed as Real Property'Must file with the County • •,• ohne
where the property is located during the twelve(12)months before March 31 of ea- :-It- •educffon is sought
See reverse side for additional instructions and qualifications.
Applicant( or contract buyer-see on reverse side) - •
. e ie, %. •0.QG On ¢ oS0J20.1 4 /' ViaL
Taxing ti Key number!legal description Record nombe Page number
'e,N AR-o G -5/0 / 660 97c5 aaec orO/ t SD79
Assessed value of real property as of Mortgage!Contract indebtedness unpaid as of • Mortgage/Contract indebtedness unpaid as of Is the appicard the sole
assessment date,arrentyear date,cement year date of application legal or equitable owner?
5 79 ❑ Yes 0 N
If no,what is his!her exact share of interest? If owned with someone other than 9lv.'wn.indicate with whom •
If name on record is different than that of applicant,indicate below. Is the property In question:Annually Assessed
❑ Real Auperty ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or seller
�r>/ LQ M i
Address of mortgagee or contact
(number and street,thy state,and ZIP code)
Name of assignee or other owner or holder of mortgage '
Address of assignee(number aid street ray,=fa,and ZIP code) .
Does appficant own property in any If yes,what county? • What Taxing District? Has lids deduction been requested If yes,state amount of deduction in other
mares? ❑Yes ❑No ?fo ❑Yes El No
A person is not entr7led 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 egtdy fine of a edit 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
Drawer NO....a
Signature of CounryNrCdor Date(month,day,year)
a I/We certify under the pens C I c1 N O• ......: , C1 we and correct and that the applicant is a resident of Indiana and
owner/contract. -r of the
Signature • ., , -- .)/ f P13-1 - -- Date(month.dal:year)
J J I3-/Z/2 m/h
F ".a•• -'-of appluuan (n ,•= and city,state,and DP code)
Person authorized by duty executed Power of Attorney or by IC 6-1.1-120.7 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$10,000.