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f ra STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
G ''t-: FOR DEDUCTION FROM ASSESSED VALUATION 77
Stale Form 43709(R13/70.15) g
�- Prescribed by Department of Local Government Finance ii 1 Its - --
INSTRUCTIONS: 1,
7o be filed in person or by mail Fonn filed with:
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought DEC l-p
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is . EP •4]&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 CountyAuditor of the coup • County Recorder
where the properly is located during the twelve(12)months before March 31 of each year the deduCra g
See reverse for additional instructions and quaff COUNTY
nt /ewlpaabvyer rims re side) (�- �J2� bar �U9SC�t�f�npR
Taxing w/�rf`/`,'�"`n't// (� / al desai r//l//Ca Y'02 .3 A
Assessed value of real property as of 1 Mortgage/Contract indebtedness unpaid as of Mortgage I Co ct indebtedness unpaid as of Is the applicant the sole
assessment date,=era year assessment date,current year date of app legal or equitable owner?
00 ❑ Yes ❑ No
If no,what is his I her exact sham of interest? If owned with someone oiler than spouse,indicate with whom
If name on record is different than that of appiicant,indicate below. property in question:Annually Assessed
eai Property ❑ AnnuallyAssessed
' • Mobile Home(IC 61.1-7)
Name of mortgagee or contract seller /�� / ,/6 \ )'
Address of mortgagee or contact seller(number and street cl4 stsa'tee,and ZIP code)
Name of assignee or other owner or holder of month: _ _
Address of assignee(number and street city state,
Does applicant own property in any If yes,what a I ( A n bEi ,state amount of deduction
other county I�IT. I` �(-,
in Indiana? ❑Yes ❑No r
A person is not entitled to this deduction unrest it is recorded in the county
recorder's office(including any home equity him 17 .rte, n-I A lC3 - seduction.
Deduction approved in the amount of r�(��'
( R4 OLL
20 20 _ 20
Signature of County Auditor f�j� 1 1 nth,day,year)
I/We certify under the penalty of perjury tit C� 1/� v� �� � ;a resident of Indiana and
owner/ ntract buyer of the aforementione --�f)�
3.1 Sig e( Z name) /L� t `-' (� —.IYC�_,ll�_\ nth,day,year)
I Full r "Dent address of applicant(number and shee v —
1/ r_I
Person authorized by duly executed Power of Afton); u.(l�' nth,day,year)
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.