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s STATEMENT OF MORTGAGE OR CONTRACT IN Tj� E$$���� bunty Township Year
:i FOR DEDUCTION FROM ASSESSED VALUATION i p i� 1► 1 , /7/
State Form 43709(R13/t0-15) 1 �--•{
Prescribed by Department of Local Government Finance
INSTRUCTIONS: SEP 2 Q 2017 _ File Mark
To be filed in person or by mail. Form filed with:
Filing Dater 1) Real Properly Must be completed and dated in the calendar year for whi ded bn' ughL
Must be filed or postmarked with the County Auditor or County Recorder o the property is `�County Auditor
located on or be!cm January
ID the immediately succeeding ce ryar OhJ NTY (�',�1jf�]ITTf�1RR /❑ County Recorder
2) Mobile I Manufactured Hanes not assessed as Real Property:Must file with t�e COpMy AUMW orTtld county
where the property is located during the twelve(12)months before Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant(owner or con 4 buyer-see restrictions on(eve",side)
0/721 Ka9 number t legal description R d number Page number
nca/r�i a /-42 -Isr- a(lQ - Coo 7a aa2 O/7 3 75 7
Assessed value of real property as of Mortgage/Contrail indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment dale,current year date of application legal or wit-*owner?
1 / 42.500 ❑ yes ❑ No
If in what is his/her exact share of interest? If owned with someone other than cprvmse,indicate with whom
C name on record S d>verent than that of operant,indicate belwr Is the property in question:Annually Assessed
• realreal Rowdy ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract rCr3
Address of mortgagee or contract seller(number and street city state,and ZIP code) -
Name of assignee or other owner or holder of mortgage - - - \ - \\c.� o
Address of assignee(number and street city,state,and ZIP code) I w�a-\S. `'t\�C,b�-� � —
Does applicant own property in any If yes,what county? What Taxing District? Has this c '.°`' o � \_�,��
in
other county ❑Yes ❑No on Prot n a _ _
A person is not entitled to this deduction unless the \�
person has a balance on the person's mortgage 5O 0 •.�J _:.xrtnt)•
recorder's office(including any home equity line of credit that is recorded in the county recorder's of ). \\`A.. , _..
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20 20 20
Signature of County Auditor County • Date(month,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 buyer of the aforementioned property on date application is filed.
Signato - (.. - Mn Date(month,day,year)
Y (9-tip -/7
Full - --,address , /Y� "l)2 5 5 -t ' ri -Z-/1/ '7`7L 70
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 r Date(month day,year)
Address of authorized person (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$10,000.
in Tr ir_ in ink_