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} STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
t' ' FOR DEDUCTION FROM ASSESSED VALUATION 1�7
�'� State Form 43709(R13!10.75)
Prescribed by Department of Local Government Finance I
INSTRUCTIONS: -- ire Mark
To be filed in person or by mail. JUL 3 2018 0 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 property is ' ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. �nl// • ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the Cou only
where the property is located during the twelve(12)months before March 31 oakelSieed qtignAstitispo R
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see reverse side) ^�
Z0. Mt/1��, �1ern i ek k L0
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Taxing District Key number--1�esrn 6 -Zo oo I 63-8-05,9- . R 7--0 Tier Page 2616
Assessed value of real property as of VO)�6 Mortgage/Contract SMebtedness unpaid as of I Mort gage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,aurant year assessment date,current year I date pf app ilwt po.. T� legal or equitalle owner?
c`�i',omfVY}� S V D D ❑ yes ❑ No
If no,what is his I her exact sham of interest? If owned with eone other man spouse,indicate with whom
H name on record is different than that of applicant indicate below. Is the upelty in question:Annually Assessed
Property ❑ Annually Assessed
__ _ 111777"" Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
lgvU EC-Cie-Nee{ CY l ll;0 mE/U DEW1u4LL
Address of mortgagee or contract seller(number and abeZi,lily,state,and ZIP code) I
4-C H74-4y
Name of assignee or other owner or holder of mortgage
J�t)),
A grijL 162 / l_
Address of assignee(number and sheet city,state,and ZIP code) d 0/(J O t'�W
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 county on property for
in Indiana? ❑Yes 1:1 No current yeah ❑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 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/contract buyer of the aforementioned property on date application is filed.
re( foe name f �/J/� � � Date(month,day,year)
A ! �� 1( � eT.Q Or) /)3-d p
.i�.y d nu 4 ,andZI e)e) "�4 1•
. • :� lS a 3nW On A CI s
-erson authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 t 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.