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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS county Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
s State Fm 43709(R13/115) T tlp��,
Prescribed by Department of Local Government Finance FIT 1 6 i D
INSTRUCTIONS: File Mark
To be filed in person or by marl. MAY :70 :A•. .
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 Mere the property is ❑ ntY ' •itor
located on or before January 5 of the immediately succeeding calendar year. county P Party �, .i
2) Mobile/Manufactured Homes not assessed as Real Property. Must file with the rnrmty Auditor of then I' '' �": Recorder
where the properly is located during the twelve(12)months before March 31 of each year the deduce' al.$-.n..., 0-
See reverse side for additional instructions and qualifications.
Applicant(owner c ntrea buyer-see res .G1bns qi
Taxing District limoumber/ desa n Record number Page number
e ' - 202-z0--ton 09C 0?2 -II 39as
Assessed value areal properly as of Mortgage/Contract indebtedness unpaid as of • Mortgage/Contract indebtedness unpaid as Is the applicant the sole
assessment date,current year assessrnend rent year date of application legal or equitable owneR
t m0N100 ❑ Yes ❑ No
If no,what is his/her exact share of interest? .r--- 'someone other than spouse,indicate with whom
If name on record is different than that of aon a--..- _ 6 3 18 Is the property In question:Annually Assessed
�{�O(/o /(— l ❑ Real Property Annually Aid
Mobile Horne QC 61.1-7)
Naas of mortgagee w contract seller •'
-Address of mortgagee or contract seller(nut .
Name of assignee or other carter or holder at Cal C� �O' ••..• ..
Address of assignee(number and street ray,s..m,and ZIP code) -
Does applicant own property in any If yes,what county? - What Taxing District? Has this deduction been requested It yes,slate amount of deduction
Indiana?other county in ❑Yes 0 N - anent year?? ❑yes ❑No
A person is not entailed 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 egwaiy fine of ae&that is recorded 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 20 20 20
Signature of CourdyAedda County Date(mouth,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.
. .,...(�% lug names) ' / '- -- / / -- Date(month,day,year)
r 5-3o- 17
oil ---iA ent address of (nu and street,city,state,and ZIP )
Person by duly executed Power Attorney or 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (manner and street Sc 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.