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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
reic)
:tf!'' FOR DEDUCTION FROM ASSESSED VALUATION
State Fonn 43709(R13 I 10-15)
Prescribed by DepaMleM of Local Government Finance p @ J
INSTRUCTIONS: 11
Tb be filed in person or by mail. rm filed with:
Ring Dates 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought O C T _ on''QQ
Must be filed or postmarked with the County Auditor or County Recorder of the county where the properly is ZCbllinty Auditor
located on or before January 5 of the immediately succeeding calendar year. c •unty Recorder
2) Mobde/Manufactured Homes not assessed as Real Properly:Must file with the County Auditor of the .• 140 ' r ri
where the property is located during the twelve(12)months before March 31 of each year the dedrn ,r -•r••
See reverse side for additional instructions and qualifications. 0 6 COUNTY AUDITOR
Applicant(owneror contract buyer-see restrictions on reverse side)
J O.,ne_n 2.0 � - • T`(`t C-�'le_l
Taxing O tgr�` `i'�'-I° '� o13- o00 • ca- oas ter' 3rel
Assessed value of real property as of Mortgage!Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,anent year assessment date,current year date of application
LY
C: legal or equitableowner?
vi US Coo . '�'esy ❑ No
If no,what is his/her exact share of interest? If owned with someone other thaan spouse,indite with whom
If name on rend is different than that of apprcant,indicate below. I Is the property in question Annually Assessed
dv-fl Annually Assessed
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_
Name of mortgagee or contract seller
•
Ca r M C s-ecl (-L. Drawer NO...................Q dry,Address of mortgagee or contract seller(number and street state.and ZIP code) `O
Name of assignee or other owner or holder of uµteage Card NO,
Lida,04O 3? ......
Address of assignee(number and sheet city,state,and ZIP code) / l37o
oDoes ther applicant own progeny in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
in Indiana? ❑Yes ❑No ,current year?roperty for ❑Yes ❑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 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 ot.
20 20 20 20 20 20 20
Signature of County Auditor County - Date(month,day,year)
I 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 filed.
1� re owLIT
Date(month,day,year)
Full
nt address of a t(nnum+ber and and ZIP code)
1 S' . L-1 ' —I SO S . .�-•F- . t R rN-- C-� ,-\)vJ . Lh�L-L9.
Person authorized by duly executed Power of Attorney or by IC e-1.1-12-0.7 Date(month,day,year)
Address of authu,iced 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 S10,000.