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STATEMENT OF MORTGAGE OR CONTRACT 1 t
Tounty Township Year
FOR DEDUCTION FROM ASSESSED VALUATIO State Form 43709(R13/10-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: OCT 1: 2018 File Mark
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 whi the dad t
Must be filed or postmarked with the County Auditor or County Recorder the property is unty Auditor
boated on or before January 5 of the immediately succeeding calendar R
2) Mobile I Manufactured Homes not assessed as Real Property: �d - Rne county ❑ County Recorder
where the property is located during the twelve(12)months before Mardi 31 of each year the deduction is sought
See reverse . additional instructions and qualifications.
Applicant era nfrad -see map' -rse side)
Intl-
/ "r�/1. .Key mrmber�I-..-/.
/y/l a�� 7 a a o air is2-c�i Record ` Page
Assessed value of ' property Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date, year assessment date, went year date of application legal or equitable owner?
• /(nnC) ❑ yes ❑ No
If no,what is his/her exact share of interest? If owned with someone 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 0 AnnualyAssessed
• Mobile Home(IC 61.1-7)
Name of mortgagee or contact seller Cf) ,71 \ /�
Address of mortgagee or contract seller(number and sac /-) "41
(J/Of2
Name of assignee or other owner or holder of mortga ` � as/
Address of assignee(number and street,city,stab 4/ . N
Yar,
Does applicant own property in any If yes,what county. 47, t ,requested If yes,state amount of deduction
other county .�
in Indiana? ❑Yes ❑No ) �6-d, es 0 No
A person is not entitled to this deduction unless the.person has a bare,. '9.(/� q sad indebtedness that is recorded in the county
recorder's office(including any home equity line of credit that is recorded a,. L e e rat is the basis for the deduction.
COUNTY AUu..
Deduction approved in the amount of
20 20 20 20_ 20 20 20
Signatu o my ditor 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 bled.
"nature ND naamme)/�T Date(month,day,}rear)
T0---//r 4
Fullieslent address of apniumpamifitet,city state,and LP 91-)
Person authorized by duly executed Rowe(of Attorney or by IC 6-1.1-12-0.7 / Date(month,day,year)
Address of authorized person (number and street 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.