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tSTATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
' FOR DEDUCTION FROM ASSESSED VALUATION
Y State Form 43709(R13/10-15)
FI
Prescribed by Department of Local Government Finance
INSTRUCTIONS:
Prescribed To 1b .5kd�
be filed in person or by mail. MAR 0 J 7U I I :
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 Recorder of the county where the property is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. . AM so,. •Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the co.41, iii;m►tr
where the property is located during the hve/ve(12)months before Mardi 31 of each year the ' �t% UNTY AUDITOR
See reverse side for additional instructions and qualifications.
Taxing Appficanttowner or auhtact See r f lrsegie e r l
Taxing District r inter/legal description t.L,,1 1�.►/ f`/ //•{f- Record Pa a tuber
b' O4-a3 - a0o-OQ3 . 1Ob- DIY f"r C/
Assessed slue of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the ap the sole
assessment data,current year assessment date, t� b year date of application legal or equitable owner?
C ❑ Yes ❑ No
If m,what is his I her exact share of interest? ' If wined 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
_ - Mob_tle Home(IC 6-1.1-7)
Name of mortgagee or contract seller --- - �! rte(`
Address of mortgagee or contract seller(number and street city,state, 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 properly in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other aunty on property for
in Indiana? ❑Yes ❑No current year? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the armuM of
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 1 contract buyer of the aforementioned property on date application is filed.
ignaNre(owner's game) 33(22, ^ DatClmon a= arL
F 0 1 1a(of applicant Own anOt�yatyfP�sfate�, n P e) �o� 3 /(1
Person authorized by duty executed Power of Attorney or by IC 2-17 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. .