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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
£'=-r FOR DEDUCTION FROM ASSESSED VALUATION .
a := State Faun 43709(R13/10-15) g
Prescribed by Department of Local Government Finance 17 9Y•-i.
INSTRUCTIONS: IL-'
To be filed in person or by marl. with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. JUL L 1 2
Must be filed or postmarked with the County Auditor or County Recorder of the county where the properly is_ County Auditor .
located on or before January 5 of the Immediately succeeding calendar year.
2) Mobile/Manufact the ured Homes not assessed as Real Property.Must file with the County Auditor of the ..r j • r i11 -. My Recorder
where e property is located during the twelve(12)months before March 31 of each year the deduction 0• .
See reverse side for addrttonalinstructions and qualifications. GIRSON COUNTY AUDITOR,
Applicant( or contrail uyer-see restriction:if side) . .
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Taxng DStruil _ lamb: ° °= ,96a a t 94 S-oa� ReardI 2• P6?3
Assessed vatue of real properN as of Mortgage/contract indebtedness unpaid as of . Mortgage/Contrail indebtedness unpaid as of is the app?cant the sole
assessment date,current year assessit date. ar date of application legal or equitable owner?
❑ Yes ❑ No
If no,what's his I her exact share of interest? If owned with someone other than spouse,indicate with whom
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If name on record is&dfecerd than that of applicant,indicate below: W
SCPnA MA J d
Name of mortgagee or contract seller (���
p g Or 4 a/ltq 6-1.1-7)
I , 1W
Address of mortgagee or contract seller(number and street,oily,state.and ZIP code) /N 'ce r �)/1 )�
Name of assignee or other owner or holder of mortgage ' r 1 i //((��i �j/L�-(1Ji'I r'-'
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•Address of assignee(number and straet,thy&foie,and ZIP code) i`iV i QDj 91 / w
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Does applicant own property In any If yes,what county? - What Taxing District? on
other county �j
in India a? ❑Yes ❑No - / 7.--al /_'1`/
A person is not mulled to this deduction unless the person has a balance on the person r to aunty '
recorder's office Including any home equrly line of area that is recorded in the county r
COUNTY AUDIT(
Deduction approved in the amount of
20 20 20 20 20 20 20
Sigma/ore of County Auditor County Date(mWh,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• -r of the aforementioned property on date application is filed.
Si nature( ., , r . .:.• • (nwrNh,day,year)
�� .l— � aa-ri
F O .`of (number and and Zl e)
3 4 �� i•
duy awarded of Attorney or by IC li-,.i-, -0.7 Date(month,day,year)
Address of authorized person (number and street,OW.state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 570,000.