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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
,t;\ �, FOR DEDUCTION FROM ASSESSED VALUATION • ii 0 to{
•17AI! State Form 43709(R131 10-15) 1-a9--t 6
`— Prescribed by Department of Local Government Finance /)1 v fIIL,
INSTRUCTIONS: . File Mark
To be filed in person or by mail fi- ••, :
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 f 2 ?'t' .:01:
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county n„
where Me property is located during the twelve(12)months before March 31 of each year the deduction is sought J L 2 O L u w
See reverse side for additional instructions and qualifications.
Applicant( or Lad -see restrictions on reverse side) /1, .i
V r • .. . h 9 n w�1 ,Jl�1La, JUr. , j b�OR
Taring District Key numbed legal d—• •i.. i'• _ a. : i !I" ■ o•(4 r 1
aonytoiN •Assessed value of real property as of MortgsaggeeM current indebtedness unpaid as of Mortgage/ uWebtedn25s unpaid aaz�of Is the applicant the sole
assessment date,amen ad legal or equitable owner?
ik Q(JO ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with ne other than�rsn,indicate with whom
If name on record is different than that of applicant,indicate below.. is the in question:Annually Assessed
Property ❑ AnnuallyAsssessed
' - - —_ Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller - _-
---Old namoi,t Bunk K i. K Excp vaTruG
Address of mortgagee or contact seller(number and street ray,state,and ZIP code) Q c
Name of assignee or other owner or holder of mortgage 18 - a p y
Address of assignee(number and street city state,and ZIP code)
Does applicant own property in any It yes,what county? What Taxing District? Has this deductit
in Indiana? ❑Yes ❑No on 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(mduding 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 i Date(month,day,year)
I f 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 I contract buyer of the aforementioned property on date application is filed.
Signature name) Date(month,day,year)
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v Fesid nad� o ( urtlber argsgget,dry,slaa-tee,,sacA:l cI•I/P��code
Al Person authorized by duly executed C\lPOwer ofAltoorney�r by IC e-1.7-12-&7 �� ) • Date(month,day,year)
Address of authorized person (number and street city slate,and ZIP code)
The penalties for perjury can include imprisonment up to two and a had years and a fine not to exceed$10,000.