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STATEMENT OF MORTGAGE OR
CT
e3 '" FOR DEDUCTION FROM ASSESSED VALUATION EBTEDN@ � n 'I `i unship I Year I
j�l{ ��r '
i' r1 State Form 43709(R13/10-15) I`, ! Prescribed by Department of Local Government Finance
INSTRUcnoNs: • OCT 1• 2018 File Marx
To be(bed in person or by marl. c , Met wear.
:song Dares:: 7) Real Propent':Must be completed and dated in the calendar year for which the deduction is ght•
Must be filed or postmarked with the CountyAudrtor or County Recorder of the county whe ❑ County Auditor
boated on or before January 5 of the immediately succeeding calendar year jjJJ�i u�v'l t,�Ty pUDIII Q�County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must h7e with the Co g€a&ttlrG4?il��T/nty
where the property is boated during the twelve(12)months before March 31 of each year the deduction is sought.
See reverse side for additional inshrlmns and auafitiications.
Applicant(o r or r•r ❑buyer-see[fjtriGiwr_ reverse side)
I 'axing District Key number!I _ aiptior. Record number _ rage number
t -otId. ,S - ) oa-voo.a.o4--Oa0 I t2-O / 8 139 %3
- Assessed cabled real noa as ofassessment ins.psrem yeea:rent
I Mortgage/Contact indebtedness unpaid as of Mortgage/Contra=ireedness unpaid as of I Is the applicant the sale
assessment cast assent year hate of appa anon legal or equitable owner?
i j •-rTes ❑ No
It no.wnat is rib/her exact snare of interest? It owned with someone other than spouse,indicate with whom
If name on rernre is dfiensa than that of applicant,indite telex. Its the property in Question:Annually Assessed
,I!Real Properly I] AnmtaM Assets r
MobDe ome(IC o-7.1-7)
dahRz
WrAdAd(ddrress orrgagee or ontra= `sellerrr(nnnuumber and street city,set , non JP code) 511
Name of assignee c otser owner or holder of mortgage
Andress of assignee(number and street,thy&rate.and ZIP oboe)
Does appiant own property in any It yes.wnat aunty? Has this
deduon been requested If yes,state annals of deduction
miser county I What faxing Dstria? Ion LropeM for
I in Inaw2% ❑Yes IJ No assent year? I I Yes 1L 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 oft-roe including any home eouity line of credii.that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR .
Deduction aoourved in Use amount al.
2
0 I 20 I 20 20 I 20 I 20 I 20
ISignature of Count/Auditor County I Date(month,day,year)
I/We certify under the penalty of perjury Mat the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
otmer f zntract buyer of the aforementioned property on date application is filed.
Signa a lora ) ` I Date on M ']
Full resident actress a applicant(ntenPae�r and stree cit J co /✓ , 7 e
1°7 �A- tlf/IDA1 %i Q� / if
Person auvxszed by duly exeuned Power of Asomey cloy IC 6-1.:.122-0.7 'rime(month,day,yeah
Address of authorced person (number and sweet 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 S10.000.