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r,� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
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:, FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
<1- Prescribed by Department of Local Government Finance
INSTRUCTIONS: _ _ File Mark
lb 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 property r • County Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the coon I i .1' -E .,er
•
where the property is located during the twelve(12)months before March 31 of each year the deduction is so t - -- row-
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer- on reverse side) NU6 6 2018
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Taxing District Key number t legal description Record n r Page m
10V _5e-nit's VI I le .la -\T-Va- ao3 . boo .Slo3- •; . . a'.r U•,
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness u of 15tlf E7!
assessment date,current year assessment date,current year daft applrztion legal or equitable
(ir r7 t �i m co UV ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned witUsomeone other than ,spouse,indicate with whom
If name on record is different than that of applicant indicate below- is the property in question:Annually Assessed
❑ Real Property ❑ AnnuallyAssessed
• Mobile Horne(IC 6-1.1-7)
Name of mortgagee or contract seller` rV`V ` f�+1 (�Cw `I — .
Address of mortgagee or contract seller(number and state,rT,W.bP wtl2/' 1 cc-cb..v� \\v.-N% ,N
-So Rr.,,,,._ C w�be,r\o--\vim -\0
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code)
a°`� _ 30`{ k.
Does applicant own property,iinn any If If yes.what county? what Taxing District? Has this dedar -
m�irdiannaa?ry ❑Yes PS-CC current year? ❑Yes ❑No
A person is not entitled to this deduction unless the,person has a balance on the person's mortgage or contrail indebtedness that is recorded in the county
recorders office(including any home equity line of credit that is recorded in the county recorders 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.
Sr• -. re owner's NU name) Date(month,day,year)
r ' 0 4 ro
Full i address of-•.•.«.r(nu and street city,state,and,
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a0authonzed by duty (Ai executed Power of mey or 61.1-12-0.7 `\V' I'-( �tj teR Date(month,day,}ear)
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.