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,,,," ..9- STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
:Ant. FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
Prescribed by Department of Local Government Finance
FILE
INSTRUCTIONS:
To be filed in person or by maiL Form Ned with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. ((��((`� 1,�{�'7
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property46LT 31IS'aunty Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the cou r 4� -
lo
where the property is located during the twelve(12)months before March 31 of each year the deduction is '�, re j t p
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see
description Record number Page number
26-19-28-400-001.879-025 Qo 11- 45'1 I
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
141300 127213.50 100,000 Eria ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is th party in question:Annually Assessed
Real Property ❑ Annually Accused
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Regions Bank dba Regions Mortgage
Address of mortgagee or contract seller(number and street city,state.and ZIP code)
2050 Parkway Office Circle, Birmingham, AL 35244
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in a If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other on property for
in Indiana? Yes No current 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 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 I contract buyer of the aforementione property on date application is filed.
Si ure(owners full name) Date(month,day,year)
Fu resident address of applicant(number and street,city,state, nd ZIP code)
ozy s7 E9sa s i+r✓h sdaJ ,l 97
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 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 ears and a fine not to exceed$10000. - ■