Mortgage_Ziliak (2) .1.-1-..7::‘sl STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Ct; Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
1'r State Form 43709(R13/10-15) � �
�-- Prescribed by Department of Local Government Finance
INSTRUCTIONS: EC 1 u 10� File Mark
To be filed in person or by mail 0 F (filed :
Filing Dates 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought .i
Must be filed orpostmaan d 5 of eCou�iatey suor County der der of the county where iv=pm Nie,Cr PUD(.� County Auditor
located on or before J ye t
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Au.7;4 tf 8�county ❑ County Recorder
where the property is located during the twelve(12)months before March 31 of each y '•, is sought
See reverse side for additional instructions and qualifications.
Applicant(owner c���toaa oyvar/ j `./ o�r, a ^
Taxing District J �/�� Key number/ Record number Page number
Assessed value of real property as of C/LIt'Mortgage/ indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year I assessment date,aarenr year date of application legal or equitable owner?
/f 78� ❑ Yes ❑ 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 appficant,indicate belo.. Is the
property in question:Annually Assessed
pfleat Property ❑ Annually Assessed
Mobile Bane(IC 6-11-7)
Name of mortgagee or contract sel / /I
Address of mortgagee or contract seller(number and street city,state,and ZIP code)- -- -
a
Name of assignee or other owner or holler of mortgage r ° i1— J 3`
� I
Q 1`2.,Y ,Z 7n—
Address of assignee(number and street city,state,and ZIP code) r C-3 Z \ 1\--1'? t 00 O . b a es Doer county ppicant own property in any If yes,what county? What Taxing Dt \ ai,- 1c\ _ I punt of deduction
in Indiana? ❑Yes ❑No \ _
• A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contrail indebtedness that is recorded in the county
recorder's office(including any home equity fine 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/contract buyer of the aforementioned property on date application is filed.
S- ipgatere( furt16) ,Ql `��'�/v� g�� Date(n.wwdr,day yeas)
• •
Full address chp number and scree{jx state,and code)
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 years and a fine not to exceed$10,0(0. _