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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
FILED
State Form 43709
Department 5)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: JUP! -M1"(.
To be filed in person or by marl. orm T_•
Filing Dates: 1) Real Properly.Must be completed and dated in the calendar year for which the deduction is sought.
Must be filed or posbnarIced with the County Auditor or County Recorder of the county where the properly'- • A at,• n Auditor
located on or before January 5 of the immediately succeeding calendar year. pps�ir,,,,..��. ' a'Itm ,,,•2) Mobile I Manufactured Homes not assessed as Real Property.Must the with the County Auditor ol�Morry COU T „,, .rhtY Recorder
where the property is located during the twelve(12)months before Mann 31 of each year the deduction is sought - - "
See reverse side for additional instructions and qualifications. 1I/1I l Don,
Applicant(owner or comzeiclons on re side) .
Taxing District Inumber I1 legal description! -�a- al - 000 .591r-ode - `teed i PU6�Y/
Assessed vaehe drawl property as of VV Mortgage f ¢�inde.byt�e�dness unpaid as of • Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
uraocebmad date,ascent year assessment date,l t ` V'-_ date of application legal or equitable owner?
If no,what is his l her exact share of interest? t (_mil I If owned with someone other than ❑ Yes ❑ No
spouse,indicate with whom
If name on record is different than that of applicant indicate below: Is the property in question:AnnuallyAsessed
• ❑ Real Property ❑ A maUy Assessed
Mobile Rome 6-1.1-7)
Hann of mortgagee or contract seller 5-13
Address of mortgagee or contract serer(number and street dry,stare,and ZIP code)
Nene of assignee or other owner or holder of mortgage '
Address of assignee(number and street aiy,state,and ZIP,--- 9:6_99
„ !�-
Does applicant own property in any If yes,what county? - VtLJ� n-'Glo I .. requested t yes,state amount•of deduction
iblame ❑yes 0 N Dra\1'CI' NO O... ............ ❑No
A person is not entitled to this deduction unless the per_ indebtedness that is recorded in the county '
recorder's office(including any home equity line of wed ar 10967 basis for the deduction.
Card NO. ......""".,... .
Deduction approved in the amount of
At I I r. 000 ffJ�
n
20 20 _ 20 I 20_ 20 20 20
Signature of CourdyAudaor County Date(mor*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
I contract buyer of the aforementioned property on date application is filed.
��.(mw,e`rs fun noon) Date(month,day,year)
Fun reyigeNO dressd NlmgMer and street cttY tor.arM ZlP ood L "l C 7V
Personn aa1`utl.u, e55ty duty executed Power or IC 61.1-12-0.7-�({)'-K, Date(month,day,year)
Address of authorized person (number and street•aiy,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.