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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
re;-;:f..1, FOR DEDUCTION FROM ASSESSED VALUATION p
State Forth 43709(R13/10.15)
`— Prescribed by Department of Loral Government Finance
INSTRUCTIONS: • File Ma
To be filed in person or by mail.
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought �u R
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year
am u corder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the Ygr where the property is boated during the twelve(12)months before March 31 of each year the deduction jf Y A t t
See re A`1� - foradditionalinstructionsandqua(' NCOUyTY..UDITOq
7 -•arcuated buyer dons;revs side)
/ sY V- Q
-•1' •o'.-.!1 Keey{g r/legel description �) .� / �t
Lam —/76.5 jOn -6(Litt On 9- d- f/ op
Assessed , -of :•• Mortgage/Contract indebtedness un as of M
,V paid engage/Contact indebtedness unpaid as of Is the or equitable the sole
-,-- °I dad,•�•year � assessment date,anent year data of application _id legal w aquiTable owneR
iT7c150. ❑ Yes ❑ No
If no,what is his/her exact share of tluaest? If owned with someone other&haft spouse,indicate with whom
If name on record is afferent than that of applicant,indicate below- is property in question:Annually Assessed
Real Property ❑ Annually Assessed
• Mbbfle Home(IC 6-1.1-7)
Names of mortgagee a contract seller ^r+m
Address of mortgagee or contract seller and bbeet.dry,state, SZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street thy ,and ZIP code)
•
Does
hes applicant t own property in any If yes,what county? I What Taxing District? (Has thit n.••uw• peen requested If yes,state amount of deduction
in Indiana? ❑Yes ❑No Yes. ❑No
• A person is not entitled to this deduction unless Do a- a9 t1 4act indebtedness that is recorded in the county
recorder's office(including any home equity fin Pit\C£d. it is the basis for the deduction.
fll ice A \Illy ccv.
Deduction approved in the amount of fl sL\e 1 JO ? -Q --Nce Co P vsc
20 20 Z\R. ,),50 - (:).° 20
l .a.)- kc& 2D 20
- -
Signature of County Auditor I 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 1 contract buyer of the afo entioned property on date application is filed.
r Signature • •na i Date(mont h,day,year)•
!r `/ 22-/Its'Full =a•- , .•. ber street dry,state,and ZIP code)
authorized duly Power of Attorney or by IC 0.1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)
The penalties for penury can include imprisonment up to two and a half years and a fine not to exceed$10,000. -- - -