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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS county Township Year
r''e FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(813110-15) / i
Prescribed by Department of Local Government Finance _P f i� iSA,
INSTRUCTIONS:
File Ma ' ' '
To be filed in person or by marl. JUN Pamn VI,0,.
Filing Dates: 1) Real Property:Must be completed and dated m the calendar year for which the deduction is sought. Erg,
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.
2) Mobile/Manufactured Homes not assessed as Real Property.Must file with the 7 ,...�. Recorder
where the property is located during the twelve(12)months before Mardi 31 of each Auddedu( 8 no et '. NT,, .
See reverse side for additional instructions and qualifications. ) Yearfhe deduction is -.+:.r,AUNTY AUDITOR
see�on reverse 4 /a 0592---x- 6 Rand number Page number
Q � d��!/ moo- ao � .3� 9- 0 � - 6/7. a�/ 3
Assessed vase of real property as of Mortgage/Contrail indebtedness unpaid as of • Mortgage I Contract indebtedness impend as of Is the apparent the sole
assessment date,and year assessment date,anent year date of legal or equitable owner?
If no,what is his I her exact share of interest? If owned with someone other ❑ Yes ❑ No
spouse.indicate with whom
If name on record is afferent than that of appirant indicate below: Is
Property in question:Annually Assessed
Real Property ❑ Armua9y Assessed
Name of mortgagee or amtrad seller Mobile{tome(IC 61.1-7)mortgagee
ffc°in gyneie
Address of mortgages or cortoad
se
numbmand street city,state.and ZIP code)
Name of assignee or other owner or holder of mortgage '
Address of assignee(number and street thy,state,and ZIP c de) DI'815' I' NO... 3C)C- -..
Dees applicant awn property in any ff yes,what county? . What Taxing District? Has this I .•• ... —on prone
other in indiannaa? ❑Yes ❑No anrenty Card NO. ,�/�/`/` —
A person is not entitled to this deduction unless the person has a balance on the person's mortga_ '•••• •. `
recorder's office(iincludmg any home egwly fine of audit that is recorded in the Y
county recorder's office)that rs hate uuao,... _._ ___
—
COUNTY AUDITOR " -
Deduction approved in the amount ob
20 20_ 20 20_ 20 20 20
Signature of County Auditor County Date(month,day.year)
•
I 1 We certify under the penalty of perjury that the above and foregoing information is true and correct and that the appfitant is a resident of Indiana and
owner/c((on�ttract buyer of of the aforementioned property on date application is filed.
P �fdtlress,�/'�Gtard� Data(month,day,Year)
adi ap ( and street,illy,state,and ZIP code) /G / Z t 7
�J/.5— t . ntca X57 c-'
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Data(month,day,yew)
Address of authorized person (number and street may 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.