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a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS county Township Year
L's'-1 FOR DEDUCTION FROM ASSESSED VALUATION j�
: ', State loan 43709(R13/10-15) FILE
Prescribed by Department of Local Government Finance
INSTRUCTIONS: _ File Mark
To be filed in person or by matt OCT 6.Tyr:
Filing Oates 1) Real Properly:Must be completed and dated in the calendar year for which the deduction is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of Otq coup tgR-emrder
where the property is located during the twelve(12)months before March 31 leach year the de duc✓ filfi611tih000 TY AUDITOR
See reverse side for additional instructions and qualifications.
Applicant(owner or contact buyer-see restrictions side)
Taxing D(i�-b�ic�t `-t{�t` U�IP,gt�-I�`� T� �x�N� Record number Page number
Assessed vatue of real property as of 4 Mortgage 1 Contract I ne u np �of Mortgage l Contract indebtedness unpaid as of II th app the sole
assessment date,current year assessment da( ,aarent year date of application legal or equitable owner?
Le MI5 1(? tea ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,inthcate with whom
If nave on record is afferent than that of applicant,indicate below- Is the property in quesa^--. ,[1
y.. �u ' kln f`�
Name of mortgagee or conttrra`ct seller t� Q n {� r PALL
Address of mortgagee or contract seller(number and street city,slate,and ZIP code)
Name of assignee or other owner or holder of iurtyege n - 0
Address of assignee(number and street city,state,and ZIP code) -
Does applicant awn property in any If yes,what county? What Taxing District? Has this dec_.on been requested If yes,state amount of deduction
in Indiana? ❑Yes ❑No acoment 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 line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDrIOR
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 coned and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
Signapfe(own $fup (i)I Date(month,daY.year)
( irll resident ent i.l_�f.;-..-c(a.4R .umberand Pcode)
Person a30 't , ! r r •���-0. `gym. �7�(pD
Person authorized by duly executed Power of Attorney by IC 61.1-12-0. ( Date(march,day,yeah
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.