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xT STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
'
e' FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709(813110.75) TT g�
�— Presaibed by Department of Local Government Finance y �--! p
INSTRUCTIONS:
Fe ED
To be filed in person or by mad. Ft
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought c 1 Z p�1
Must be filed or postmarked with the CountyAudrfor or County Recorder of the county where the property is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. Coon Re der
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the properly is located during the twelve(12)months before Mardi 31 of each year the deduction is
sa
See reve sidefor additionalinstructions and qualifcations. + SOI4 COUNTY AUDIT R
Applicant( or/gA t buyef \see resbtYions on rave ' )•
Taxing° (Key
- b-2 D - oV . 433-naf Record Page
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Assessed value of real property as of Mortgage I 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?
3 Li I Orb ❑ yes ❑ No
If no,what is his f 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 the property in question:Annually Assessed
❑ Real Property ❑ Mde Flome(IC(IC•
Name of mortgagee a contract seller ) i J r� n
Address of mortgagee or contract seller(number and street,city,slate,and ZIP code) R/J�w(/ J _ �p
Name of assignee or other owner or holder of mortgage V 6)0 ri-- S e ' tar„.4 _
Address of assignee(number and street,illy,slate,and ZIP code) \P " 0, z5s,,, r•'•'t1C
Q d �,` —
Does t awn property in any If yes,what county? What Taxing District? on th
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in IMiana? ❑Yes ❑No amen
• A person is not entitled to this deduction unless the person has a balance on the person's mortgayc _. y
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)that is me.,.._-
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/contract buyer of the aforementio p operty on date application is filed.
Signature • ✓= me) bor Date(month,day,year)
•(` ,2,,,207
RAI j address of app (num arch stmt oily state,and ZIP code)
-arson 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 years and a fine not to exceed$10,000.