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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
L,-4 FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13!10-15)
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---- Prescribed by Department of Local Government Finance '
INSTRUCTIONS: I I. . t
To be filed in person or by mad. Form filed with
F i l i n g D a t e s: 1) R e a l P r o p e r t y.M u s t be c o m p l e t e d and dated in t h e c a l e n d a r y e a r f o r w h i c h t h e d e d u c t i o n i s sought. II II iI II 1 0 f }}7
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Must be filed or postmarked with the County Auditor or County Recorder of the county where the proper** `U County Auditor
located on or before January 5 of the immediately succeeding calendar year. • County Recorder
2) Mobr7e/Manufactured Homes not assessed as Real Property.Must file wilt the County Auditor of the
where the property is located during the Melee(12)months before Mardi 31 of each year the ded -is
See reverse side for additional instructions and/qualifications. .';r° '9jn►f/►i
Applicant(owner or gwftrad see restriction qi rryerse side) GBSOM CD�J n17Y Al r11TnR
• r ) r ASR/'/I/Yl/1771 t Lt /1
` hA tic ( 1 "u t •,- -09-- aoyoo.- 5�-oaa fwd _ Id7 D
Assrssedvalue of real properly as of Mortgage!Contract indebtedness unpaid as of - Mortgage/Contract indebtedness unpaid as of Is the ape/want the sole
assessment date,currant year assessment date: ar date of application legal or equitable owner?
o ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with'someone other than spouse,indicate with whom
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If name on record is different than that of applicant,inchoate below: ifs the property In question:Annually Assessed
❑ Real Property ❑ ArmualN Assessed
n Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller ', '
'_-- -.�__ 1 A .a_ ./ il //1/ •
y,state.and P...e)
LoA0F1.104 i (J✓UtifyG )
i 00
✓O/ /1/ I/ r aI / 'What Taxing District? Has this deduction been requested If yes,slate amount Dt deduction
on FrOPerlY for current year? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity fine of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR' - - •
Deduction approved in the amount of
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20 ! 20 2�0//y/ 20 20 20
Sicyrature ,�,., - ••,I/1,(f l--f / ll County Dale(month.day,Pearl
I e certify under the penalty of perjury that the a Ia.to�gang information is true and cored and that the applicant is a resident of Indiana and
owner!contract buyer of the aforementioned property on date application is filed.
Signature(. - rug ., :) Date(month,day,year)
S d ads_ A 4.1-1,4! Lai:
- .1 --.erd-.,: — of-... r. and street -; r&and ZIP code)
VT 3 CO E rS 4t s- 5* incc;\On S f-f l W-1 v
a nt:teemed by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street&y,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.