Mortgage_Schmitt -, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County_ Township Year
'',1 FOR DEDUCTION FROM ASSESSED VALUATION
-- State Form 43709(R13/10-15)
�- Presrnbed by Deparbnent of Local Government Finance F I J J FI f }
INSTRUCTIONS:
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar war for which the deduction is sought/FA is g 7 20 7,—,/
Must be filed or postmarked with the County Auditor or County Recorder of the county where the prior County Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobi le/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of county 0 unty Recorder
where the property is located during the twelve(12)months before March 31 of each year the ded
See reverse side for additional instructions and qualifications. _GiBgarg rant INTY AUDITOR
Applicarst(./er' �l � f� �0s )/ & , / / l ( I I
T....g r'. Key nu /t descri Record number Page number
a �01-( oo-00 1s l4 —Oc�7 ao►7 Ssr
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assesamerrt ddUa�1 r COO date of application legal or equitable owner?
! (�{ CC- ❑ Yes ❑ No
If no.what is his/her exact share of interest? / If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below. Is the property in question:Annually Assessed
❑ Real Property ❑ Annually Assessed
• II Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller L S
Address of mortgagee or contract seller(number and street city,state,and ZIP code)
Name of assignee or other comer or holder of mortgage
Address
•
Does at Drawer NO zing District? Has this deduction been requested If yes,state amount of deduction
other a on property for
in Indian current year? ❑Yes ❑No
A persoo, Card NO. ince on the person's mortgage or contract indebtedness that is recorded in the county
recadei red 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 20aken 20 20
S' tun lof my qud'fpr G 4a. County Dot(month,day,yeah U)Li/liAj�/-J(/Gl t�-L6
I/We certdy 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.
ig re(milers e� Date(month,day,yew
Frdent address of applicant(number and street city,state,and ZIP code)
I(-7 a{ E iSe) s � , Win/ 19 7670
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,yea)
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. . - .
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