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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
Slate Forth 43709(R73/70.75)
Presorted by Department of Local Government Finance
INSTRUCTIONS: 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 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 I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is located during the twelve(12)months before Math 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Appbcg comer or contract
1�on (P��- _ on rev'e JKeg nuSrnpra6�on �] r'1 �^ 2
T S `l_ `' • h lQ _ -kO O V .J�T Record nl�nQ/h/1erzt
Paters
Assessed value of real property as of (Mortgage I Contract i debtedness unpaid as of Mortgage/�indebtedness unpaid as of Is the applicant the sole
assessment date,current year assesvrent date,current year �datt-al
legal or equitable owneR
5�' _ ❑ yes ❑ No
If no,what is his/her exact store of interest? If owned someone other titan cpouve,indicate with whom
If name on record is different than that of applicant,indicate bekrw Is the property in question Annually Assessed
❑ Real Property ❑ Annually Assessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
,, , cY NI d - uin fI-LE-13
Address of mortgagee or contact seller(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage oCT 1 S 'to}�'j
Address of assignee(number and street city,state,and ZIP code)
.i
r,, .,„'m►n��1� pR
Does applicant own property in any If yes,what county? What Taxing District? Has this dedu•i.• a r t nry. ,state amount at deduction
other county on pro
in Indiana? ❑Yes 0 No currentPey205 r Yes 0 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 aedit 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
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 coned and that the applicant is a resident of Indiana and
owner I contract buyer of
the aforementioned property on date application is filed. �./ J��'ea) p
II\la
10.
crro
I resident address of apDlaUM(n mber and street city slate,and 21P code) /
Persoonnaau{tthorized by duly/execute/ d Power of Attorney or by IC 6-1.1-12.0.7 Date(month,day,year)
Address of authorized person (number and sheet d0,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.