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as STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
E - �'' FOR DEDUCTION FROM ASSESSED VALUATION FILED
r �, State Form 43709(R13/10-15)
� -- Prescnbed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by malt O C T '• 'f r
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 is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. - Ili +'ty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the CountyAuditor of the coun , .: 1,�r Fri
where the property is located during the twelve(12)months before March 31 of each year the deduct/obit/Brig rig C 1 : • • is t:
See reverse side for additional instructions and qualifications.
Appamsthovrneror contract buyel_see restriclic on reverse side)
Taxing Key number/legal description Record n r Page number
_ 11 - fib-\ —ICI .-2o4 -0o1 .31y -02-C 2-01 51
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant ttte sole
assessssnrent date,current year assessment date,current year date of C.Z. legal o iabte owner?
� 6 O coO Yes ❑ No
If no,what is his/her exact sham of interest? If owned with someo other s indicate with whorn //////111111
If name on record is dferent than that of applicant indicate below. Is the property in question:Annually Acsocarid
❑ Real Property 0 AnnuallyAssessed
' Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract saner
Address of mortgagee or contact seller(number and sheet city,state,and ZIPFode) -
Name of assignee or other owner or holder of mortgage Drawer i O Oa) 1
}�
Address of assignee(number and street city,state,and ZIP code) 5 I
Card N O. - '
Does applicant own property in any If yes,what county? What Taxing District? Has d .
other county on pn
in Indiana? ❑Yes ❑No current year? LJ yes Li NO I
A person is not entitled to this deduction unless the,person has a balance on the person's mortgage or contrwt indebtedness that is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20 20 20
SnaMre of County itor .}.) County. - Date(month,day,ye
X tut Auditor
1V� • c N\75o✓1 . io — Ii — I -
I/We certify under the penalty of perjury that the above and foregoing infor atio 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 filed.
Sig fua name) ) �(month,day,year)
X address of applicant(numbs city,state,and ZI code) / `•n 1 1 _ I er '
Z S L • -- �Yanc g(1- L �j JX
Person authorized by duty executed Power of Attorney or Ic e-1.1-12-0.7 l 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 two and a half years and a fine not to exceed 510,000. - __- _