Mortgage_Denbo (3) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS IP Township Year
; FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15) �I��/
' Prescribed by Department of Local Government Finance
INSTRUCT7ONS: OCT- 1 8 2017 File Mark
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)?sought ,�/
Must be filed orposfmarked with the County Auditor or County Recorder of the county wligla� •C) County Auditor
located on or before January 5 of the immediately succeeding calendar year. ��
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the( 61¢14bdWofI1TeYco°rr4 ITOR ❑ County Recorder
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional in and qualifications.
Applicant(ownerwamhao buyer...- sonDwrs on•_._VL (�_ )'n
10 . District Key I legal tl -- t_ Record r Page corm r
l l�cdon (-I -1- l ol -coo.7(a-o 1 �(3
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sk
current c
assessment dale,current year assessment date,are n
r date of application legal or equitable owner?
❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than c1nucP,indicate with whom
If name on records different than that of applicant indicate below. Is the property in question:Annually Assessed
❑Real Property ❑ Annually Assessed
• Mobile Home(IC 61.1-7)
Name of mortgagee or contact seller 1V'I/v]�V/1{ /+
Address of mortgagee or contract seller(number and street, . , ,aid- Z1P'code) - fl ` a
Name of assignee or other owner or holder of mortgage _
Address of assignee(number and sheet dry,slate,and LP• DE NI 80t
1 M, 'PR� ()GetzA r� /1)
Does applicant own property in any If yes,what county? r X 1'V G 1 ✓- equested If yes,state amount of deduction
other county
in Indiana? ❑Yes ❑No i ID No
A person is not entitled to this deduction unless the pr 10— C�f indebtedness that is recorded in the county
recorder's office(including any home equity line of cn ✓/• the basis for the deduction.
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.
lean(•. ` n , e) Date(month,day,year)
/ ad. -.yof app•- t(nu and = ,state,and LP code)
, 7� f c• �1! ,t/f/G/t/4 / /vice-ri� �q76 ?J
Pe • authorized by duty executed ower 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. .