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s STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION �j-f g
State Form 43709(R13!10.15) ri gN
"-- Presated by Department of Local Government Finance
INSTRUCTIONS: _ File Mark
lb be filed in person or by mail •. - .!� -.'M18
Filing Dates 1) Real Property.Mud 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 property is , ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. �� ,M __;'-,_.'.-.. •
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the teats 0N " ', -IC er
where then �r y is located and during twelve(12)months before March 31 of each year the deduction is sought" - . 'UDITOR
See reverse fir
Applia (•- •- or contract buyer-see on reverse side)
iiiit tuber/legal description 70.77 Pa �j f% / / esj ar- 007 c.J o67d 2
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,want year assessment date,parent year date of application legal or equitable owner?
10 c) ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than'spouse,indurate with whom
If name on record is different than that of applicant,indicate below: Is property in question:Annually Assessed
J Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Nam of mortgagee a canted seller / q/
Address of mortgagee or contract seller(number and area city,state,and ZIP•••e)
Nam of assignee wother come re Cl��I �
Address of assignee(number and � , d ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property br
in Indiana? ❑Yes 0 No current year? ❑Yes. D 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 recorded in the county
recorder's office(induding any home equity line of credit that is recorded in the county recorders office)that is the basis for the deduction.
COUNTY AUDIT( - - --_
--
Deduction approved in the amount of: ,r Mr r IJ,vL S me-6;04,0,0
20 20 20_ 20_ .7()/8 — /G,-a
Signature of County Auditor County `�/-cJ
I/We certify under the penalty of perjury that the above and foregoing information is true are w••v.... _. and
owner I contract buyer of the aforementioned property on date application is filed.
( Signature(owner's(full nn�aame�),,,,�,,y.� Date(mouth,day,yea)
(
l Full resident address of applicant(number and street,city,stale,and ZIP code)
ors Fr III!anis p(In c<rorl 11U y7670
Person authorized by duly executed Power 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. .