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s STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE r Township Year
ill-'2" FOR DEDUCTION FROM ASSESSED VALUATION pi I
I -'- State Fonn 43709(R13I 10-15) ` _ mw I p ���
Presalbed by Department of Local Government Finance
INSTRUCTIONS: SEP 7 - 2018 File Mark
To be filed in person or by mail. Fenn filed with:
Fling 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 -rty is in County Auditor
located on or before January 5 of the immediatety succeeding calendar year. �'� tr;;&um-r a R
2) Mobile I Manufactured Homes not assessed as Real Pro Must file wit Eot/rityAu&g-of the county � County Recorder
Pity
where the property is located during the twelve(12)months before March 31 o each year the deduction is sought.
See reverse side for additional instructions and qualifications.
Applicant(owner baa -see/es/Lawn,on reverse side)
o� N L. L7/24a 7
Taxing District Y Key number/legal desaiption Record numbe Page number
en • zd- 7- i3-/CO- m /. 79'/ - oz I 201'� 351-3
Assessed valve of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the apptiant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
❑ yes ❑ No
It no,what is his/her exact share of interest? If owned with someone other than cpru.en,indicate with wham
If name on record is different than that of applicant,indicate below. Is the property in question:Annually Acvaeed
Real Prtgpt4 t % "y. .c -Irk
.
Name of rages or contrail seller • 611
* r
AD-Aqa
Address of mortgagee or contract se➢er(number and sheet city,state,and ZIP code) SEP 7 Z010
Name of assignee or other owner or holder of mortgage .
Address of ) Drawer NO
assignee(number and street illy,state,and LP code KOI 3IBSON COLINI`t r.c:r,t.�"
Does applicant own property in any If yes,what county? S ��
in Indiana?
Yes ❑NoIf yes,state amount ofdeduction
cure ? ❑ Car
d NO.
A person is riot entitled to this deduction unless the person ha 1 4 less that is recorded in the county
recorder's office(rrlduding any home equity line of credit that, 4 etc( aim for the deduction.
COUNTY AUDITOR
Deduction approved in the amount ot.
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.
biunanhre( M5 r Date(month day year)
° !/`/ 5- 7-/K
F • dress of (nu and street city,,fate and ZIP code)
6/ 7 7 �f'/�c/ 45 4a.....,.. /p ti 7106S
P n authorized by duty executed of Attorney or by IC 6-1.1-12-0.7 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 Iwo and a half years and a fine not to exceed$10,000.