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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
�. StateFmn 43709(R13/10-15)
Prescribed by Department of Local Government Fiance 1
INSTRUCTIONS:
F1 F•.a,. ,fir}
To be filed in person or by mad. Form filed with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought. I I I'
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property}s` 21 /County Auditor
located on or before January 5 of the immediately succeeding calendar year ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property.Must file with the County Auditor of the •.; r where the property is located during the twehe(12)months before March 31 of each year the deduction :. .p�. a'
,� y: r'mi., •
See reverse side for additional instructions and qualifications. GIPSO h' COUNTY AUDITOR
Applicant orrxhnc twyert se istrictie reverse rode /C
Tor" 9,Distla F/./� Key number/legal sadesviption -!/ Record number Page number
4.2 v e n t ' R (o- 2,0 - /7 - 30O - oot 7Ya1 -&O / ?h0 / 7 / (037
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of - Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,and year assessment date,and year date of app[�tionO O O legal ❑equitable ❑ No
If no,vital is his I her exact share of interest? If owned withi someo�neC//ootither than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is the property in question:AnnuailyAssessed
❑ Real Pluyesty ❑ ArmuallyAssessed
Mobile Home(IC 61.1-7)
Name of mortgagee or contract seller E -r F c u - -
Address of mortgagee or contract weer(number and street,city,stale,and ZIP code) 1 7- /6
3 - -
r ____
Name of assignee or other owner or holder ofmortgage ' ,Af bra 11'er' ),h " AO Qdp_ —•
•Address of assignee(number and street,sly,state,and ZIP code) 'I/4/VA ,(y •�,•••
PT NW Sw 17 -3 - 9 /• y35A4- C7r•dNro vcic
Does applicant own properly in any If yes,what county? - What Tmdng District? Has this demi....--. I
other county ❑Yes ❑No current years ❑Yes UM, l J•
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recome..
recorder's office(including any home emery fine of credit that is retarded in the county recorders office)that is the basis for the deduction.
COUNTY AUDITOR " •
Deduction approved in the amourd of:
20 20 20 20 20 20 20
Signature of CoumyAuddor - Couuhty Date(month,day,year)
•
I/We certify under the penalty of perjury that the above and foregoing infmmabon is true and coned and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
C``jnat uq�r e!uH nartue) ^ Date(month,day,year)
/rtdl resident address of applicant(number and street,city,state,and ZIP code) .dek
'f 6.3-(17 e Sf R4 id F ?'hetrc)t .2-r LI 7Ggr?
Person autodzed by duty exerted Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authored person (number and street sly,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.