Mortgage_Aders aJ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
t q;: FOR DEDUCTION FROM ASSESSED VALUATION
'f. State Form 43709(R13110-15)
- Presorted by Department of Local Govemnent Finance g 4File k II
(03 Itl( r
INSTRUCTIONS: •
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 We deduction is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property AN 2 ( nil tEPounty Auditor
located on or before January 5 of the immediatety succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the CountyAuditor of the county
where the property is located dump the twelve(12)months before March 31 of each year the deduction is slJugh
See reverse side for additional instructions and qualifications.
(• •era contract buyer-see restriction on reverse side) ,
CIDCON '.nJNf? nowwIVH
�Y' I a �. �i 1- .a 1 V
g Datrict Key number r -...description Record n e number
-cJp- \ 2. .0$ - a01 - 0o1 _ `l5o -o07 l(40
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,current year date of application legal or equitable owner?
I b I l 1.S LfYes ❑ No
If no,what is his/her exact sham of interest? If owned with someone other than spouse,indicate with whom
tf name on record is tlRfenxnt than that of applicant,indicate below. the property in question:Annually Assessed
Property ❑ Annually Assessed
Mobile Horne(IC 6-11-7)
Name of gcrtgage..re or tray seller _ /� (�,
X l - S •1 CECIL —.
Address of mortgagee or contract seller(number and street city,slate,and LP code)
Name of assignee or other owner or her of mortgage ^ -
Address of assignee(number and street city state,and ZIP code) /�'W l r l 1 / r Mal)
Does applicant own property in any N yes,what county? IC��" ^If yes,state amount of deduction
other
in Indiana? ❑Yes ❑No _ _
• A person is not entitled to this deduction unless the person h I I ness that is recorded in the county
recorders office(including any home equity line of credit the 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 coned and that the applicant is a resident of Indiana and
owner!contract buyer of the aforementioned property on date application is filed.
Signature(.• -.. ) Date(month,day,year)
dhs 6m street City.state.and LP e) /
fa 3 G7� ! S� /A /.r>er�ZV At- `I 76 )U
f' •n authorized by duly execute�Power of Attorney or by IC 61.1-12:1.7 Date(month,day.year)
Address of authorized person (number and sheet 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. - - -