Mortgage_Strickland (13) ', FOSTATEMENT OF R DEDUCTION MORTGAGE OM SSESSED VALUATION INDEBTEDNESS County Township Year
�, State Form 43709(R13/10-15) FILE
Prescribed by Department of Local Government Finance
INSTRUCTIONS: • File Ma
To be filed in person or by mail. • MAY 9ormEtiffut
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought ❑ County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where the properly is
located on or before January 5 of the immediately succeeding calendar year. tyltecerder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the coup y.(f,
wham the property is located during the Melva(12)months before Il}arGr 31 of eadr yearthe ded�OUNTY AUDITOR
See reverse -• • additional instructions and qualifications.
Applicant(i :- r (7,--/
T.•„ ... . Key number!legal description Page
Q / ., 0-03 - /da • coo. 933-00/ 676 6779
Assessed value of real as yy as of Mortgage/Conract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment dater assessment date,current year data of appf+rz i n / . / l legal or equdlande owner?
Ljrindi ❑ Yes ❑ No
If no.what is his I her of interest? If owned with someone other than spou.,.., atefr+flh whom
If name on record is different ten that of applicant indicate belay. Is property in question:Annually Assessed
Real Property p Annually Assessed
Q l obtle Home(IC 6-1.1-7)
Name of moe a contact seler Address of mortgagee a contract seller(numeet city,sore.and e) ,4
I
Name of assignee or other owner or holder ol �
CIL 3-3-9 V(f_13,492-
Address of assignee(number and sheet city, e, 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 on 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 credit that is recorded in the county recorder's office)that is the basis for the deducgon.
COUNTY AUDITOR
Deduction approved in the amount of
- _
20 20 4o i 5' - o 3
Signature of County Auditor Drawer NO nodh,day,yeah
•
•
I!We certify under the penalty of perjury that the above and h Card NO. t is a resident of Indiana and
owner!contact buyer of the aforementioned property on datE
NiC .'r!ers fu8name�( ( I north,day,year)
Fu l resident address of applicant(number and sheet cdy,state,and ZIP code)
l" 5-56 a S. R S E , oc-LA--a G% I1 , 3_-N 4.77+0
Person authorized by duly executed Power of Attorney or by IQ 6-1A-12-0.7 Date(month,day,year)
Address of authorized person (number and street cdy,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.