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�.s.� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATIF 1 J
State Form 43709(R13/10-15) �Ti
Prescribed by Department of Local Government Finance g 111111 •
INSTRUCTIONS: FEB 2 2 2017 File Mark
lb be filed in person or by mail.
Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought �,/
Must be filed or postmarked with the County Auditor or County R-•• the •q' u ;;.. + e property is L7 County Auditor
located on or before January 5 of the immediately succeeding celend-.r.(::1 • Wilt.
2) Mobile/Manufactured Homes not assessed as Real Prope fyf r . .�.j 0: c• i the county ❑ County Recorder
where the proa•ly is located during the twelve(12)months A arch 31 of e year the deduction is sought
See reverse sie-t addition 41:9 and qualifications.
Applicant(own: .. dbr)yer-set S1rr'V
, ' / number
e q v �1 /_0/_100 - 00V. 66/Ma7 /7 X574
• =.value of real property as of Mortgage I cl indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole •
assessment date,current year , poi) date of appli atron legal or equitable owner?
❑ Yes ❑ No
If no,what is his/ter exact share of unerest? If owned with someone other than spouse,indicate with whom
If name on record is Sd;erent than that of applicant militate belo r is the property in question:Annually Assessed
❑Real Property ❑ Annually Assessed
^ Mobile Home(IC 6r1.1-7)
ksice)Name of mortgagee or contract seller
ly//�/
Address of mortgagee or contract seller(number and sheet city,state,and ZIP 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 If yes,what county? What Taxing District?
other county
in Indiana? ❑Yes ❑No J tr[P L C
A person is not entitled to this deduction unless the person has a balance on the peso n�•n1-r-��L J^ county
recorder's office(including any home equity line of credit that is recorded in the county Cf"t I M v Fl
COUNTYAUDII 7 /71 1(0
Deduction approved in the amount of: �J l
20 20 20 20 20 20 20
Signature of County Auditor 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 applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signature net's hill me) Date(month,day,year)
kill resident address of a ken umber and "r,state,and ZIP code)
Y)/g03 w I< /U rert NC- cj-o J N %'7(i7D
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 sheet 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.