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STATEMENT OF MORTGAGE OR CONTRACT-INDEBTEDNESS 1 Coo tv 1 Township I Year I
FOR DEDUCTION FROM ASSESSED VALUATIONStateFne37D9(F;?;10-15)Prescribed by Department of Local Government Finance
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INSTRUCTIONS:
To be filed in person or by mad. 11/0v L-
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Piling Dates: I) Real Properly:Must be completed and dated in the calendar year for which the deduction is sought e/
Mast be filed or postmarked with the CounlyAuditor or County Recorder of the county where the p arty is 2 , County Auditor
boated on or before January 5 of the immediately succeeding calendar year. Gm I County Recorder -
2 Mobile/Manufactured Flames not assessed as Real Property-Must file with the County l
whets the properly locaiec'during the twelve(12)months before Math 37 of each year the d
See reverse ..=for additional instructions and qualifications. /yj>'
Aopecant(o `ern camardG ouye�- ° ioons rave 1 uo
Taxing District (J Ir(ey number r legal description (f I Reams n I Pa a num d as
1 a4'-)a-o7 aoV-ooa .S3S- vas abase'
- Assessed valuereal properly of. Mortgage I Contract iindaoledness unpaid as of Mon gage r Contract indebtedness unpaid as of Is the dse
assessment mote,=nest year assessment,gate.anent year date of appleadm legal or owner?
L7"Yes ❑ No
It no,what is his her exact snare of ae:est? If wined with someone��er u- n spouse,'indicate with whom
If name on Teepees different than that of took:ant,indicate below- i is petty in question:Annually Assessed
Popery O Annually Assessed
Mobile Haire(IC 6 1.1-7)
N ^ .engages Or=roam s&ler
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dress of mortgagee or comae saki(number and street pry,sre.ant ZIP ceder
IName of assignee or otter owner or holder of mortgage
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Address of assignee(number and street oily,state,and ZIP code)
Does applicant own property in a (4vet wrist county? What Taxing Distric? Has this deduction been requested If yes,state amount of deduction
ether county on property for
r lnoiarla? ❑Yes ,J No anent year? Li Yes [1 No I I
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 fine 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 at
20 I 20 I 20_ I 20 I 20 20 I 20
Signature of County Ai-stator (runty I Date(month,day,year)
I I We certify under the penally of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner f contract buyer of the aforementioned property on date application is filed.
S- fur owners lull name) !Date(month,day,year;
I /o-a19—)
D resident Tess of applicant(n r and el city sta rid ZIP ad
�3DLk ( t %rP 2a>2 r ee+&, Lnie 10
Person auonorae°by duly executed Power of Aaomey or by IC o t,1-12-0.7 I (.month,day,year)
IAddress of authoreed person line rber anc street thy,sate.and ZIP cadre)
The penalties for parry can include imprisonment up to two and a half years and a fine not to exceed$10.000.