Mortgage_Dehartra STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
;; FOR DEDUCTION FROM ASSESSED VALUATION i-
„..... State Forth 43709(R13/10.15)
Presorted by Department of Local Government Fiance
INSTRUCTIONS: File Mark
To be filed in person or by mail. SEP 2 �n Form filed with:
Filing Dates 1) Real Property:Must be completed and dated in the calendar year for which the deduction is so t'l?
Must be filed or posbnarked with the Courtly Auditor or County Recorder of the •• yr, where the properly is $ County Auditor
located on or before January 5 of the immediately succeeding calendar -- ♦/ ,, .?=dt' i County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file a;',10• ••' 7. e county
el
where the property is located during the twelve(12)months before March 31 of each •::•u-••. is sought
See reverse side for additional instructions and qualifications. ' ” "TOR
Applicant(owner w contract -see restricdars on reverse side) £fie:/ �f
Taxing District Key number I legal description Record ` z �mb 1
/ OAT- x10-�o - r9h-ioo oa, c2 QC.oa / `
Assessed slue 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,current year assessment date,aarerd year date of application legal or equitable owne
sm r?
O a c5,50 ❑ yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than crow,indicate with whom
If name on record is different than that of applicant indicate below: Is the property in question:Annually Assessed
❑ Real Property ❑ Annually Assessed
Mobile Hone(IC 6-1.1-7)
Name of mortgze or contract seller /7
Lro 017)A (2-n 977 a rZ cell n/b W
Address of mortgagee or contract seller(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and sheet city,state,and ZIP mm+dM
Does applicant own property in any If yes,what county? ��I"1 — " I t 1 in requested If yes,state amount of deduction
other county
in Indiana? ❑Yes ❑No C)'9Q ter' of s ❑No
A person is not entitled to this deduction unless the I Q id indebtedness that is recorded in the county
recorder's office(including any home equity line of c c- ��_pa. �Jr� is the basis for the deduction.
C c\c Q Z a :SS 000
Deduction approved in the amount ot. -,
20_ 20 20 I 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 I contract buyer of the aforementioned property on date application is filed.
Signature(owner's name) Date(month,day,year)
Full resident (n and city,state,and ZIP code) /Z°�/Zq,
I-9i - c,zSA/ mc&c9v5(/It-to_ /v 41- 45
Person a • ed by duty executed executed Power ofAtt mey or by IC 61.1-12-0.7 / 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.