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,,,,r,.._. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
' �:-« ` FOR DEDUCTION FROM ASSESSED VALUATION
�'� State Form 43709(R73/10.15) .
�-• Prescribed by Department of Local Government Finance
INSTRUCTIONS:
To be filed in person or by mail. onn led 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 Recorder of the county where the proliMits2 8 2111 1 County Auditor
located on or before January 5 of the immediately succeeding calendar)rear. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the County Auditor of the county
where the properly is located during the twelve(12)months before March 31 of each year the..:. • .0
See reverse side for additional instructions and qualifications. I-- - *AMU
Applicant(,owwneror contact buyer-see resat o�nss onreverse side) OIBSON GOUNtY AUDITOR
�*1 vti kKeyn �r]Ile legal T Distffd Key nu !legal description Record rtter Page number
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the apptcant the sole
assessment date,anent year assess ent date,aurent year date of applicatio/n- legal or equitable wmeR
tom? ?, dOD ❑ Yes 0 N
If no.what is his 1 her exact stare of interest? If armed 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
' MobOe Hone(IC 6-1.1-7)
Name of mortgagee or contract seller
cd-r.tet c, u.
Address of mortgagee or contract seller(number and t city,state.and ZIP code)
Name of assignee or other owner or holder of mortgage -- -
Address of assignee(number and street city,slate,and ZIP ca 3W,Data /r l. hl-f.SALL-
Does applicant own property in any If yes,what county? %/t - /� I ested If yes,state amount of deduction
in Indiana? ❑yes ❑No • / ]No
A person is not entitled to this deduction unless the pens rbtertness that is recorded in the county
recorder's office(including any home equity line of credit basis for the deduction.
Deduction approved in the amount 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 infomlation 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.
'\ Signature ner's 11 a Date(month,day,year) //�
\ t ent dress of a p t(num and street city,sta nd ZIP code) (i/�.9/ZO!/
X �!L S. ut S- ../cnr-7 /.v y76ncY
Person authorized by duly executed Power of Attorney o IC 6-1.1-12-0.7 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. .