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, t, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Year
4 ' �
FOR DEDUCTION FROM ASSESSED VALUATION �j ,
Stalefvm43709(RiSllals) g IL E *,
�
Presented by Department of Local Government Finance
INSTRUCTIONS: AUG 1 PeMdrk
To be filed in person or by mall. Form filed :
Filing Dates: 1) Real Property.Must be oornpteted and dated in the calendar year for which the deduction is sought sought the
1s Canty Auditor
located on or before January 5 of the immediately succeeding calendar year. - I`'•
2) Mobile 1Manulactured Homes not assessed as Real Property.Must file with the County Audit� nt rt NTY ,®CaZ3l�l�Recorder
where the properly is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant( a art txryer-see �O`] onre e)i .
Taxing District Kel(err description _ Rerad P number
•Assessed value of real (3 3b ate. . 0236--0 193
properly as of Abrtgage/Contract indebtedness unpaid as of - Mortgage A Contract unpaid as of Is the apps and the sole
assessment dale,aarem year assessment date,current year dye Sl- ^ legal or equitable owner?
U no,what a his/her exact share of interest? If owned wilt someone other !than"7/\ ❑ Yes ❑ No
spouse,indicate with whom
if name on rend is descent than that of appf®nt,indicate below: Is the property in question:Annually Assessed
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Wane of mortgagee or contract seller A-Q-112 4/�,ytr� r/`�p(it
Address of mortgagee or contact seler(number and street,thy,slate,and Vie) • \ U
Name of assignee or other owner or holder of mortgage ' \I ( 4 (( ,^,
•
Address of assignee(number and street,rd1;state,and ZIP code) /0 1 — p t 3(-q
Does applicant own property in any If yes,what county? . What Taxing District? 000��� ` (�(� 1 lotion
other county in Indiana? DYes El No Fce e th,\ ` I
A person is not entitled to this deduction unless the person has a balance on the pars 1 county '
recorder's office(rndudng any home equity fine of credit that is recorded in the count ' I
COUNTY AUDI `�{ O ,p
Deduction approved in the amount oY. ` ` 1 � \ C_ •
20_ 20 20 20
ic\n2cAtc*
Signature of County Author Carry (q-(-1- q(� �]
I/We certify under the penalty of perjury that the above and foregoing infomrafian q - )C L( l ` L oa and
owner I contract• - • •- ...--/ ... . -• - • •- -: -'.. - -••..-a a on date application is fled.
Sgnahue/ t,—. JIP(/if/L%VGGG Date(month,dal:year)
v :..ressofapcl ant(numberandsbeeg .; sfa r. .... _- :,.e)
} : -T r' 'fur Arka-af #A.tas,n 7 rAJ 4474 3 9
--•.-.:uther¢ed by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,rul1: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.
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