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4c STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
' ` kr FOR DEDUCTION FROM ASSESSED VALUATION
ra_ :- State Fonn 43709(R13/10-15)
-- Prescribed by Depalgfknt of Local Government Finance
INSTRUCTIONS: _- File Mark
To be filed in person or by mail. Form filed with:
Filing Dates' 1) Real Properly Must be completed and dated in the calendar year for which the dedudion is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the pm s ❑ County Auditor
boated on or before January 5 of the immediately succeeding calendar year. L a •....1 Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the
where the property is located during the bveke(12)months before Mardi 31 of each year the Marfurtion is sought
See reverse side for addtfionat instructions and qualifications. - .
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T-•a,.- r' /'/( Key nnumbeerrrlll llegS desdesrnp8Atr 7 \ 1!,,{-�C//.�,./G/ G/f`B/ ;r"O 17L•� co l Pag/elnu^mbber'
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r �_•wants of real p as of Mortgage •!Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid Nary A Is gkant the sole
- - date,current year assessment date,agent year date of application 2p �Y'Y1 �r citable owner?
6d � ❑ Yes ❑ No
t no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant indicate belvr Is the property in question Annually Assessed
%Real Property 0 AnnualyAssessed
Noble Home(IC 6-1.1-7)
Name of mortgagee or contract seller?j
Address of mortgagee or contract seller(number and scree - _ - /�
Name of assignee or other owner or holder of.yytee /I / 1 . �/
Drawer NO. ;0l X S/ p. 0 l
Address of assignee(number and street % , +-t r r
Card NO. .....LI3 `I
Does countyarn own property in arty If yes,what countel- requested If yes,state amount of deduction
other .
in Indiana? ❑Yes ❑No I0_ 71. • b v ar soo ❑No A person is not entitled to this deduction unless then.,.._1t____ S f indebtedness that is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county maw........... .. a 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 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/contract buyer of the aforementioned property on date application is filed.
Signature(ovm4511, Date(month,day,year)
IN
Full resident address of applicant(number are sheet city,state,and ZIP code)
1\ j3oZ w Cla(w0o6 Cr // L.La o/I / ti Y )079
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized 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$10,000.