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., STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
OtaFOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(Rl3/10.15) 'e I1
Prescribed by Department of Local Government Finance A ./E '
INSTRUCTIONS: File Mark
To be filed in person or by mail. JUN 2 3 Ri>thr filed WM:
Fling 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 proper is -• ty Auditor
located on or before January 5 of the immediately succeeding calendar year. r�
2) Mobile/Manufactured Homes not assessed as Real Property.Must hie with the CountyAuditorof the •.1'' • '�ml►iir Courtly Recorder
where the property is located during the twelve(12)months before Marsh 31 of each year the d N "•"- T - • OR See reverse side for additional instructions and qualifications.
Applicant(owner or buyer see
�//�h�/�/-restrictions Are �
Taxing District number description
Y' 1 09^• S I-v" x R P rlmber✓e
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Assessed value dread as of �J Mortgage!Contract indebtedness unpaid as of Mortgage I Contact indebtmlness unpaid as of Is the app5wtl the sole
assessment date,current year assessment current year date of appfi ation legal or equitable owner?
❑ Yes ❑ No
If no,what is his!her exact share of interest? �I t owned with somewre other than cp'e'c ,indicate with whom
If name on record is different tan that of applicant,indicate below. Is the property in question:AnnuallyAsessed
❑ Real Properly ❑ Mo Assessed
essed
Mobile Home(IC 61.1-7)
Name of mortgagee or contract seller I‘ ,rte
Address of mortgagee or contract seller(number and sbee4 thy,state,and yJl PV{`ilia)
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Name of assignee or other owner or holder of mortgage '
Address of assignee(number and sheet oty,r
Does applicant own property in any If yes,x n duction been requested If yes,state amount of deduction
other county in Indiana? ❑Yes ❑No /�l t ❑Yes ❑No
A person is not entitled to this dedurrirn l Drawer O GQQ�LLL ( a or contract indebtedness that is recorded in the county
recorder's office(including any home equ ifice)that is the basis for the deduction.
Deduction approved ill the amount of Card NO. 4.4.3.5
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20 20 ' I 20 I 2u I zu 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!contract buyer of the aforementioned property on date application is filed.
Data(month,day year)
0.
�Futr (�',�`o^�fJap v�baandsome istate, Pcode) /} 996 ^0
a d by&fl executed PPOwerr r /me or bbyyIIC 6-1.1-12 .7 - (�'/-y„` ,// Date(month,day,year)
Address of authorized person (number and�stree�bf—'t otyt state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 510,000.