Mortgage_Bryant .•es. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
•'t'° FOR DEDUCTION FROM ASSESSED VALUATION i L�'�
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- - State Form 43709(R13/10-15)
•' '4" Prescribed by Department of Local Government Finance
INSTRUCTIONS: DEP' Pgatit,t7
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought
Must be filed or posbnadced with the County Audrtor or County Recorder of the county where the property i p • •- •uditor
boated on or before January 5 of the immediately succeeding calendar year. I. ' •'Ire•, Aunty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of y.1 r'0 NTY AUDITOR
where the property is located during the twelve(12)months before March 31 of each year the ded rs sough(
See reverse side for additional instructions and qualifications.
r wcorYad see on side) • - n
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Key •number Page number
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Assessed value of real property as of 1 Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment dare,current year assessment date,current year date of application /a�,/�a legal or equitable owner?
(J Cl Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,&urn ate with whom
If name on record is afferent than that of epodcent,indicate below. Is property in question:Annually Assessed
®Real Property ❑ AnnuamgAssessed
Mobie Houle(IC 6-1.1-7)
Name of mortgagee or )contract seller ` LIC
Address of mortgagee or contact seller(number and street city,state,and ZIP code)
Name of assignee or other owne •4,!t.•- ftimrge. / S ALS /7 ,r
Address of assignee(number and •,.j% ,state,and ZIP code)
Does applicant own property in any If yes,what county? hat Taring District? Has this deduction been requested If yes,state amount a deduction
other county , 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=aided in the county
recorders 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
(a o _S(on
Drawer NO...,g0.1 .. ..
Signature of County Auditor County
I/We certify under the penalty of perjury that the above and foregoing information is h Card N O, .( 4 I /) and
owner I contract buyer of the aforementioned property on date application is filed. _ 11 ^,�I l-�/•r�..{/t
1 Sgna ure • er e) l L/ �/ W�
S- 3—1
trresidentad• I nt(num ands, - te,and ZIP code)
t% h>�r' 4. i�L Ste/ 1�t � t �Jl) If76 4`8
Person authorized by duly executed Paver of Adorney 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. .