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s STATEMENT OF MORTGAGE OR CONTRACEli County Township Year
E�� . FOR DEDUCTION FROM ASSESSED VALUAAONL
State Form 43709(R13110-15) 11. 2Q�d
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Presorted by Department of Local Government Finance APR OO
INSTRUCTIONS: • File Mark
To be filed in person or by mail. ' •j; Fonn filed with:
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for 1.1, :l jw r. t .-u ` I.
Must be filed or postmarked with the County Auditor or Counlist fgcprit9r6aG34•• ere the property is County Auditor
located on or before January 5 of the immediate succeedin ca7end_ar ar.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county ❑ County Recorder
where the property is located during the twelve(12)months before Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
App Sant(awnetyr fra000 ct buyer-see re. ' iwu legal al description`�
T C}.rf ("1''�,_AV—`"')te, number iption Record number Page number
2 -1a - 6S -zo3-taoz.fos9 oa & 2o/ tis /f
Assessed value of real property as of Mortgage!Contact indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,orrrennt year date of application legal or equitable owner?
7 O V / ❑ Yes ❑ No
If no,what is his!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 bets. Is the property in question:Annually Assessed
iProperty ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller o fS n — —
Address of mortgagee or contract seller(number and street city,state,and ZIP code) 4 18, O -r1'Sy.
Drawer NO ''a 18
Name of assignee or other owner or holder of mortgage
I
Address of assignee(number and sheet,ci y,state,and ZIP code) C aI>1��(- A)
• TO. I I
Does applicant own property in any If yes,what county? what Taxing District? D int of deduction
other county .
in Indiana? ❑Yes El No I c.current year/ LJ Yes LJ 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
recorders office(including any home equity line of aedit 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 ntract buyer of the aforementioned property on date application is filed.
Sig tuft name) Date(nandh,day,year)
•
Ital resident dress of app t(number and street city,slate,and ZIP code)
/9o,2 74/0.- �U 41'4 to lrn T - 5'7(,70
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,stale.and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 310,000.