Mortgage_Cox a STATEMENT OF MORTGAGE OR CONTRACT INDEB S fl. Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15) .� .J_El
• Prescribed by Department of Local Government Finance
INSTRUCTIONS: FEB 26 2018 File Mark
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Properly Must be completed and dated in the calendar year for which the is ou
Must be filed or postmarked with the County Auditor or County Recorder of the cop_ perry is County Auditor
located on or before January 5 of the Lmnediately succeeding calendar year n f'r1r;N_rY AUDITOR ❑ County Recorder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file t -CounttAuditor of the county
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 instructions and qualifications.
Applicant r��7o/Mr contract buyer-see ressttricfions on re side) r
an / /T - .�.an. (Lc
District o Key number I Record number Page number
(pi— ,2 — /1/ -/0.3 O/3, ,-Oo .02• , aG 30/,a
Assessed,rWue property as of Mortgage/Conrad indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is Is the applicant the sole
assessment date, year assessment date,current year data of application legal or equitah'e caner?
c5300 d ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
7Ptopertyc:2_ ❑:n.uanyAssessed
bile Home(IC 6-11-7)
Name of mortgagee or contract selrle/rL//7 �fl�/,'`,
Address of mortgagee or contract seller(number Jd st�� � code)
- •
Name of assignee or other owner or hairier of mortgage Drawer NO /0- '
Address of assignee(number and street city,state,and ZIP code) 36 I //
Card NO, VVV Le 000
Does applicant can property in any If yes,what county? What Taxing District? Iuction
other in county ❑yes ❑No l airrent year?? ❑Yes. ❑No f
•
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorders offco(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 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 1 contract buyer of the aforementioned property on date application is filed. -
Signature(owners Marome) Date(month,day.year)
) R . G .
Fullasiden1 address of applicant(number and street city state,and ZIP code)
9522 Ear Will R. Oau hint N-■x .J 417C4
Person authorized by duty executed Power of Attorney or by IC&r1.i-12-0.7 Date(month,day.year)
Address of authorized person (number and street may,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed S10,000.