Mortgage_Crase STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Township
Year
f ; FOR DEDUCTION FROM ASSESSED VALUATION gay,
'II% State Font 43709(R13/10-15) g •_
Prescribed by Department of Local Government Finance �"J
INSTRUCTIONS: ., JUN 0 ( -
To be filed in person or by mail. Form 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 or postmarked with the County Auditor or County Recorder of the county where the pro ns M. - = my Auditor
located on or before January 5 of the immediately succeeding calendar year. �'I County Rector e�
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County AvEA®9tb1`W r�QgblNTy UDIToR U3
where the properly is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructiiolnsna�nd qualification.tr Applicant(off _ Mryer� 1... ce )
i\ 26 IZ-01 — ti0 ' c9p2 .0Sq -02-8 Record
ai 3 Page
ZZ3 (0
Assessed value of real property as of Mortgage/Contact indebtedness unpaid of Mortgage/Contract indebtedness unpaq.�s of Is the applicant the sole
assessment date,current year assessment date,current year date of C pS.J legal or equitaa'e owner?
500 ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with son other than spouse,indicate with whom
If name on record is different than that of applicant indicate below. le roperty in question:Annually Assessed
Real Property ❑ Annually Assessed
Mobile Home pc 6-1.1-7)
Name of mortgagee a contract setter net)), '
1 lN+ v-nn Flir\("1U
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and sheet,dry,Mate,and ZIP code) msc.I-IAEL. Cr? 36
Does
oer county own property in any If yes,what county? What Taxing District? Nast R.
- i
in Indiana? ❑Yes ID No aurre is- w'` .�, 8to
A person is not entitled to this deduction unless the person has a balance on the person's mar 'nty
recorders office(incudmg any home equity line of credit that is recalled in the county record(
COUNTY AUDITOR
Deduction approved in the amount at
20 20_ 20_ 20 20 20 20
Signature of County Auditor County Dale(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/contract buyer of the aforementioned property on date application is filed.
Signature(owyery rue Date(month,day,year)
Full FuGresiid/ennt address of appfx:ant(number and sheet illy,sate,and ZIP code)
X 3/6 .5. Gf,h/Onl St A-ftJee-fc t,), 3A) '-/76 7(2
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,Mate,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. • - -
