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a,< . STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Co Township- Year
7. -Ads FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
Prescribed by Department of Local Government Finance IIIIII...
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INSTRUCTIONS:
To be Ned in person or by mail. a - *t!,
Filing Oates 1) Real Property.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 0 j I County •uditor
located on or before January 5 of the immediately succeeding calendar year. g����
2) Mobile/Manufactured Homes not assessed as Real Property Must We with the County Auditor of the county 0 Y Recorder
where the property is located during the twelve(12)months before March 31 of each year the deduction is .
See reverse side for additional instructions and qualifications. 018 lgq
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r shict/ xey�y mbar r Record numbe ben
Assessed value of real property as of Mortgage t Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as Is the apptirant the sole
assessment date, assessment dale,anent year date of apprration legal or equitable owner?
073-0 A? ❑ Yes ❑ No
If no,what is his/her enact share of interest? I If owned with someone other than spouse,indicate with whom
If name on record is dw`erent than that of applicant indicate belwr te property in question:Annually Assessed
Real Property ❑ Annually Assessed
• Mobile Hare(IC 6-1.1-7)
Name of mortgagee or contract seller
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Address of mortgagee or contact seller(number and street city,state,and ZIP code)
Name of assignee or oth�er �holder.0 mortgage / (n/
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Address of assignee(number. -. city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? —I Has ththiiseddeeducion been requested If yes,state amount of deduction
other county ❑Yes ❑No — _ current year? ❑Yes 0 N
A person is not entitled to this deduction artless the pen I�'7/,1�,(•�,,(} ,J1�r rdebtedness that is recorded in the county
recorder's office(inducting any home equity line of and e basis for the deduction.
Deduction approved in the amount at. /`
20 20 20_ O n _ / /�/( � i 20 20
Signature of County Auditor I ,I(– �-'#' `J Date(morph,day,year)
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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 cot r -ct buyer of the aforeme boned property on date application is filed.
Signature , 'fun . Date(month,day,year)
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` Fug • , ,... – of...:. city, and ZIP code) /,
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P. • authorized d executed Power of Attorney or by IC&1.142-0.7 1 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 510,000.