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''t' FOR STATEMENT DEDUCTIOON M FROM ORTGAGE ASSESR SED CONT VALUCT ATION INDEBTEDNESS County Township Year
'� State Form 43709(813110-15)
` Presalbed by Department of Local Government Finance
INSTRUCTIONS: de Mark
Tb be filed in person or by mail. DEC 2 Fonn filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sougm- 2��6
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is L7 c%ounly Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Pro Must file with the County - ❑ County Recorder
Property: �'� o yT-'1♦%h' t
when the property is located during the twelve(12)months before March 31 of eaeAq ...-e y.' Yt,.'� t
See reverse side for additional instructions and qualifications.
Applicant(owner or con a Mr
elli
-see rests verse side)
tuber/ number Page number
� v' =1a-dd- 0oo.8�s-oav RemI1d1/V1 5
Assessed property as Mortgage/Contact indebtedness unpaid as of Mortgage I Contract indebtedness unpaid a�of Is the applicant the sole
assessment de' current year surgt year 0 date of application legal or equitable owner?
❑ Yes ❑ No
U no,what is his!her exact share of interest? t If owned with someone other than spouse,indicate with whom
tf name on record is different than that of applicant,indicate below- Is the property in question:Annually Assessed
❑Real Property ❑ AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller Q ,'i{/Y1�
Address of mortgagee or contract seller(num Q26 and BP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code)
Does applicant own property in any I If yes,what county? 'What Taring District? Has this deduction been requested If yes,state amount of deduction
other county n.,_--r_,-'_ _ - on property for
in Indiana? n current year? ❑Yes ❑No
A person is not K.. e on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office �yY1 h,- -211Adit 1 in the county recorder's office)that is The basis for the deduction.
f�JJ )LINTY AUDITOR
Deduction appror J z {(O
20 '.0 20 20 20
1
Sign_ ' • r / County Date(month 1 ay year)9-,6
I/We certify under th penalty of perjury that abcPiKuw foregoing information is true and correct and that the applicant is a resident of Indiana and
owner!contract buyer of the rementioned property on date application is filed.
Signature owners fug norms,) Date(month,day,year)
4Full resW' err a applicant(number and street,city.state.an YJP code)
b 7/67 Stier q to , . 0!A r ems- .5 I/f lie )--i- .-T V.2663—
Person authorized by duly executed Power of Attomey or by IC 6-1.1-120.7 Date(month,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. .