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`E xr r STATEMENT OF MORTGAGE OR CONTRACT IND - S 11- Township Year
• FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13110-15) -. • 1R
Prescribed by Department of Local Government Finance
ws7RUCnoHS: DEC 14 016 File Mark
To be filed in person or by mall. Form feed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the • �•- -r••{t"��,�•tr��r��
Must be fled or postmarked with the CountyAtdrtor or County Recorder of the ...I:•.-, ."1_ ) Ripple B ounty Auditor .
located on or before January 5 of the immediately succeeding calendar , ON GOU
tit
g ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property.Must lite t4 3N County Auditor of the county
where the properly is located during the twelve(12)months before Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant contract buyer restrictions reverse side) .
1L�Taxing Key description Remrd number Page number
CfraL -aO-027-too 000 0 ' a o 20/ Sea 9
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the appleare the sole
assessment this.ament year assessment date,affront year date of application legal or equitable owner?
( 706 ❑ Yes ❑ No
If no,what is his f her exact share of interest? If owned with someone other than coolle.,imitate with whom
If name on record is different than that of applicant,indicate below: is property In question:AnnualyAssessed
• oaf Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or=trap seller Si,
Address of mortgagee or contact seller(mantes and street,oily,state,and ZIP code)
•
Name of assignee or Cara owner or holder of mortgage ' •itkeR r 700 CO^
Address of assignee(number and street ahy,slate,and ZIP code)
Drawer NO c9bl
Does appfaant own property in any If yes,what county? • Wtat Taxing I ate amount of deduction
other county
tndfana? ❑
in Yes No • C�s.,1 _
A person is not whiled to this deduction unless the person has a balance Card NO. �d s recorded in the county
recorder's office(including any home equdy ffne of asst that is recorded i ductton.
COI
Deduction approved in the amount of •
20 20 • 20 20 20 20 20
Signature of County Auditor C.aunty Date(=rah,day,year) •
I 1 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 filed.
Sjcinahae(owner's me=al Data(month,day,year)
resident address of applicant(number and street city,state,and ZIP code)
1:7 C-u 6 rilAck 11 (4 7
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,all:state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed S10,000.