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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
' .a FOR DEDUCTION FROM ASSESSED VALUATION
State Font)43709(R13/10-15)
I t" �
`— Prescribed by Department of Local Government Finance ' : ; r
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INSTRUCTIONS: • I ' • "
To be filed in person or by mail. 0 r 5 Fv fwd"'m.
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the dedtction is sought '/
Must be filed or postmarked with the County Auditor or County Recorder of the county where the properly is Illff County Auditor
located on or before January 5 of the immediately succeeding calendar year. ,t',nu Recorder•
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor the "
where the property is located during the tNelie(12)months before March 31 of each rira
year t•1NTY
AUDITOR
See reverse side for additional instructions and qualifications. A UDITO
APW cant pr�on on reverse side)
rtdatijj/Gi ? a - Go/ 5��a,/ aim ���G r of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year date of application ,r !D / legal or eW 'e ownefl
j✓' V ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than epru.en,indicate with whom
If name on record is different than that of applicant indicate below Is property in question:Annually Assessed
Real Property ❑ AnnuallyAssessed
Mobile Home QC 6-i.1-7)
Name of mortgagee or contend setter
a
Address of mortgagee or contact seller(number and street city,state,and ZIP code)fe /Namhe of assignee or other ovmer or Colder d mortgage n`/ 9 � /s' c
Address of assignee(number and street city,state,and L
al
Does applicant own property in any If yes,what county? - What Taring District? Has this deduction been requested If yes,state amount of deduction
other in Indiana? ❑Yes ❑No on �? ❑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 fine of credit that is recorded in tha mane-—corders office)that is the basis for the deduction.
I R
Deduction approved in the amount
20 20_ DI"aWel. NO I 20 20 20
Signature of County Auditor. t /).. • Date(month,day,year)
Card NO. �h
41.)-/ I!We certify under the penalt tie and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the;__-_..._..__.._..„..po,.y un on application is filed.
Sign3tlir (owners tuff name) Date(month,day,year)
Full ad of applicant(number and sheet city state,and ZIP code)
t• Sjj. r j'o t✓_ O&-' n f yr i/,. rh 47'7666
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Data(month,day,year)
Address of authorized person (number and sheet 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.