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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count Township Year
<- ;i FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
�— Prescribed by Department of Local Government Finance "'
INSTRUCTIONS: MAY ii i Y'
To be filed in person or by mail. •rm led with:
Filing Dates 1) Real Property:Must 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 prope .' P. . --- Auditor
located on or before January 5 of the immediately succeeding calendar year. I l'. -7 . it; County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Audi `•y w I'N a
where the property is boated during the twelve(12)months befae March 31 of each year the ded- is so r C
See reverse side for additional instructions and qualifications.
Appantoovactr contract buyer-see restrictions on reverse side) C
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Twiny District i Kei.number/legal desaipton Record number Page number
1a-13- DA- 400 - col, 1 Q Sl - n0 lo AN A k Di
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,current year assessment date,current year date ��application Cr) CO legal or equiowner?e owner?
4t r ❑ 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 below Is fety in question:Annually Assessed
Real Property ❑ Annually Assessed
Noble Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)1
Name of assignee or other owner or holder of mortgage —�/ —
Address of assignee(number and sleek city,state,and LP code) 672 I //y
D l'81yCT NO CT v q/
Does applicant own property in any If yes,what county? i If yes,state amount of deduction
other county
in Indiana? ❑Yes ❑No Ca(-fl NO. o
A person is not entitled to this deduction unless the person hi .riness that is recorded in the county
recorders office(including any home equity line of credit that is rcw...o.,,,._-_____., is 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 coned and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signature/(/� e) /Q'/ Date(month,day,yearn
F ' 'ra of app hm r and k WY,state,and LP code) �� �
4Person authorized by duly executed Power of Attorney or by IC e-1.1-12-0.7 Date(month,day,yea')
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.