Mortgage_George ,�„a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
')' State Form 43709(R13/10-15)
�- Prescribed by Department of Local Government Finance
INSTRUCTIONS: .. File Mark
To be filed in person or by mail. Fonn filed with:
Filing Oates: 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 is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the County Auditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant(owner or contrail buyer-Tstricdons on reverse side _
T IZ6—�S-1t-') 23-o0O . 6UPI -026 . 2-0I 1�-
R
Assessed value of real popery as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of l Is the applicant the sole
assessment date,current year assessment date,a,rtent year date qpliiatiom
V V O Q I legal or equitable owner?
❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with Bone othelthan spouse,indicate with whom
If name on record is different than that of applicant indicate below: Is in question:Annually Assessed
Real Property 0 AnnuallyAssessed
Moble Home(IC 6-1.1-7)
Name of mortgagee or contract seller old 1\cd6oAckit clunk -- _-- FILED
Address of mortgagee or contract seller(number and street city,state,and LP code) T }(�
48
Marne of assignee or other owner or holder of mortgage OCT
1�i O,. L V�,f� ---
Address of assignee(number and street city,slate,and LP code) `l IL_. :�Ir-4y
GIBSOM r LAITY AUDITOR
Does applicant own property in any If yes,wt at D / .p 7_ a 6 / on been requested If yes,state amount of deduction
county 0
in Indiana? ❑Yes ❑No ❑Yes ❑No
A person is not entitled to this deduction ui Drawer NO oonbact indebtedness that is recorded in the county
recorder's office(including any home equi )that is the basis for the deduction.
Deduction approved in the amount of Card NO.
20 20 I " __ I — 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 I contract buyer of the aforementioned property on date application is tiled.
Sig�tiflpr�(owners fug nameh �/ Date(m0 Q ar)Q
eeyl�/l�)..}M. �u^' . 71'L0� 1� l0 IQ �I U •
Fully dentaddresse�app" t(nu r and street,city,state.and ZIP code) 111
WO S 00,mV Flu 3T\
Person authorized by duly executed Power of Ad9mey or by IC 6-1.1-12-0.7- Date(month,day,year)
Address of authorized person (number and street city,state,and LP code)
The penalties for perjury can include imprisonment up to two and a hat years and a fine not to exceed$10,000.