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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS 4 i u ?I _ i'.!r=hip Year
`` ° FOR DEDUCTION FROM ASSESSED VALUATION
+--.7 -^ State Forth 43709(R13 f 10-15) MAY 0 2 2017
Prescribed by Department of Local Government Finance
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INSTRUCTIONS: F e Ma r
lb be filed in person or by mail. I ,, • -flm1 j; Form filed with:
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the deduction is -•
Must be filed or postmarked with the County Auditor or County Recorder of the county i -t, 4)¶ ,� . TY AUOIS y�{�
ounty Auditor
boated on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is boated during the twelve(12)months before Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant(ownegf or cconnb/b/yaa buyer-see restrictions on reverse side), ale.-n.
Taxing District Key number l legal cation � Record number Page number
26 -70 50° °oO g7,3 F 1O / d6/1 /5 &!-
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
7300c) ❑ 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 bebvr. Is the property in question:Annually Assessed
Aj�',Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract!' / /'''/� Li
Address of mortgagee or contact seller(number and street city,state,and ZIP code) . --
Name of assignee or other ovmer or holder of mortgage ^!\
Address of assignee(number and street city.state,and ZIP code) Drawer NO 96 / 3
Does applicant own property in any If yes,what county? What Taxing District? /c/ , r n deduction
other in Indiana? ❑yes ❑No crud \O.
G (�C ({/
A person is not entitled to this deduction unless the person has a balance on the pc l ?°. - n the county
recorder's office(including any home equity line of credit that is recorded in the ow; ( lJ .
COUNTY AUDITOR • -
Deduction approved in the amount of
20 20 20 20 20 20 20
Signature of County Auditor County - Date(month,day,year)
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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 afore toned property on date application is filed.
Signature(Q�'n ll ) 3 i Date(month,day,year)
/j/�Y[ (ll
Full resi0 add ��(number andsfreet,city,state,an ZIP code) r �J
P authorized by duly executed Power of Attorney or by IC 1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,slate,and ZIP code)
The penalties for perjury can include imprisonment up to twv and a half years and a fine not to exceed S10,000.