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STATEMENT MORTGAGE CONTRACT
County ship Year
� FOR DEDUCTION FROM ASSES SED VALUATION.
State Form 43709(R13/10-15)
Presarbed by Department of Local Government Finance
INSTRUCTIONS: _ til
e Mark
To be filed in person or by mail. DEC 2 2 ZD Forum 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 postmarked with the County Auditor or County Recorder of the county where the .,.petly i; �i a County Auditor _
boated on or before January 5 of the immediately succeeding calendar year. : `��1 n�County Recorder
2) Mobile/Manufactured Homes not assessed as Rea/Property:Must file with the County Auditor.•7�.ice 1 A(jDR)rt
where the property is located during the twelve(12)months before March 31 of each -. c. ..> •.. :- Ntf)% t -
See reverse side for additional instructions and qualifications.L (�
ant( con/raj/1 buYer ;on`V )7 )/� / ltg /5
T Key number/legal description Record number Page number
/sth . % ) dd --(0? -O7-ago.5-Ua3.397-art anr7 ,51/at,
Assessed value of real property as of ortgage I Contract indebtedness unpaid as of Mortgage I_ eaehpb)6dness unpaid as of Is the applicant the sole
assessment date,current year ssessment date,current year date of appl ./��� legal or equitable owner?
❑ Yes ❑ No
If no,what is his/her exact share of interest? I If owned with someone other than spouse,indicate with whom
If name on record is di ferent than that of applicant,id below. Is property in question:Annually Assessed
Real Property ❑ MnuallyAssessed
Mobile Home(IC 61.1-7)
Name of mortgagee or contract seller 041C421/
Address of mortgagee or contrail seller(number and street city,state,and ZtPP code)
Name of assignee er X,,,,/2 57.2/ , /
Address of assig and street,ay,state,and7JP code)
Does aco�t awn property in any If yes,what county? %Mat Taring District? I Has deduction been requested If yes,state amount of deduction
in Indiana? ❑yes ❑No (�.-•-ent.vear7 ❑Yes• ❑No
• A person is not entitled to this deduction unless the person has a balance on the pc: --"--Innss.that is recorded in the county
�.._
recorder's office(including any home equity line of credit that is recorded in the coo �
COUNTY A /* / I— I7 076)//'-'5C0(0 I
Detluction approved lo the amount of:
20 20 20 20_I # - .0
Signature of County Auditor --Zc 1N04 1
-5 ST�'A/mI
I/We certify under the penalty of perjury that the above and foregoing intern /"/1 %nkfi�L� /Indiana and __
owner/contract buyer of the aforementioned property on date application is CJT Y'
S i g n a u r e(o w n e r's ND name) I 5�} 3 3•vq J
TTLxr ` �t( snoi�
Full resident address of applicant(number and street,ay,state,and ZIP code)
3 ed . executed l/A-,c,lJe�'.di.er27 mvK�o
Person authorized by duly executed Power of Attorney or by IC 61A-12-0.7 ' .
Address of authorized person (number and street ay,state,and ZIP code) -- I
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed S10,000. - ., .