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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
ci, FOR DEDUCTION FROM ASSESSED VALUATION County Township Year
State Fonn 43709(R13110-15) �(Presvthed by Department of Local Government Finance N , p ��
INSTRUCTIONS: 9 FF Ftle Mark
To be filed in person or by mad 11 Form filed with:
Filing Dater 1) Real Property.Must be completed and dated in the calendar year for which the a is�ught
Must be filed or postmarked with the County Auditor or County Recorder of the county where the pro•- is County Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with th- a• , •yr?#• then�!�Quyg ❑ County Recorder •
where the property is located during the twelve(12)months before March 31 of-_.i,';-1.-, Twit:•_ •�Sffirrylrt
See reverse side for additional instructions and qualifications. GiwSON COU
Applicant(mrrren or contract buyer 5dej '
Taxing Disiri;{/ , Key number/legal description Record number nun r
VV al a-59- a33c� / 59 0/9 117 ' �
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of •
Is the applicant the sole
assessment date,turned year date of application legal equiteNe owner?
?
s rTU ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record S dherent than that of appficant indicate below Is the property in question:Annually Assessed
• ❑Real Property ❑ AnnuafyAssessed
• Mobile Home(IC 6-1.1-7)
Nacre pf mopgyge or con / „ —'/�"��^/�-�/J��
Address-offmatgaagee or (number and/street,city,state.and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and Zt
•
Does applicant own property in any If yes,what county? .. requested If yes,state amoum of deduction county
in Indiana? ❑Yes ❑No Drawer NO••-• ••O�... ❑No
A person is not entitled to this deduction unless the p indebtedness that is recorded in the county
recorder's office(including any home equity line of cn ,,, he basis for the deduction.
Card NO. ..... ..
Deduction approved in the amount of
20 20 20 20 20 20 20
Signature of County Auditor County • Date(month,day,year)
I f 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 buyer of the afuiementioned property on date application is filed.
Signature(owners full'name) ., Date(month,day,yea)
rX,f riku ( "' •`[ uldar�'¢ oi`a(T'`l�•y/� �.._ and street, Yafa.and ZIP code)
P ed by duly exgan- = of•w mey or by IC al.1-12.0.7 Date(month,day,year)
Address of authorized persona (number and street city,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.