Mortgage_Livermore (3) . STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou Townshi Year
FOR DEDUCTION FROM ASSESSED VALUATION
�': State Form 43709(R13 f 10-15)
�— ` Presabed by Department of Local Government Finance J
INSTRUCTIONS: • :13 t( �� �g To be filed in person or by mail. Farm filed with:Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought
Must be filed orpostmarked with the County Auditor or County Recorder of the county where the property i 7 -�� •• • ditor
located on or before January 5 of the immediately succeeding calendar year. • r V '�.: r{vR�,�rder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor off_b get n.,(�OI,NTY A e f1 UR
where the properly is located during the twelve(12)months before Mann 31 of each year the dedtucdt))tt''33'' • t —
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see " bnls on reverse side)
cl
Toting District
/ r /51ri lL-(a- aa3 • ea . (e3.� •oi do/2 number
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,amend year assessment date,arrant year date of application legal or equitatie owner?
� 2 d tSD ❑ 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 appb ant,indicate below. Is the property in question:Annually Assessed
Property ❑ Annually Assessed
• Mobile Hone(IC 6-1.1-7)
Name of mortgagee or Contract seller
Add js of or (number and street city,state,and ZIP Code)
Name of assignee or r owner or holdezof rrortgage
Address of assignee(number and street city,state,and ZIP code)
Does applicant own properly in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other County , property for
in Indiana? yes ❑No current year? ❑Yes. ❑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(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 t contract buyer of the aforementioned property on date application is filed.
Signature(owner's tub name) r",
Date( / day,year)
/� far lit,tiw al Ile ?a l
Full address of applicant(number and sae+et city.state,and ZIP code)
' 70C N U- - 4.l— PP:ncre<0\ reti Cf2-6-a
Person authorized by duly executed Paver of Attorney or by IC 6-1.1-124.7 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 hat years and a fine not to exceed$10,000.