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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
�.�; FOR DEDUCTION FROM ASSESSED VALUATION
ormPres ibe 43709(parm nt )
o �. s
Prescribed by Department of Local Government Finance
INSTRUCTIONS: x
file Mark
To be filed in person or by mail. �^ 1 filed with:
Filing Datas: 1) Real Property Must be completed and dated in the calendar year for which the deduction is so t �_.�```��1 \%
Must be filed or posbnarked with the County Auditor or County Recorder of the county where the propel M. '•unty Auditor
located on or before January 5W the immediately succeeding calendar year. wilt ... "{ Recorder
2) Mobile/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 March 31 of each year the deduction is so
See reverse side for additional instructions and qualifications. r o 'J `
App cant(owner or contract buyer-see restrictions on reverse side) SIN -
Par-ne_\ Cam. J• • Abs- rf'Cr1 . �,\9
Tagngt a y tuber I legal'^ ' - ^ OOO. Record number Page number
0-7
no
Assessed value of real properly as of ILL„)Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unppaa�leQ as of Is the applicant the sole
assessment date,current year assessment date,current year date of application (_,U legal or�eqowner?able owner?
1aO , OW, L7res ❑ No
If 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 below: Is the property in question:Annually Assessed
❑Real Property 0 Annually Assessed
• Mobile Horne(IC s-1.1-7)
Name of mortgagee or contract seller
E Q.r\SV-1llL Cr-cAt k tinlon .
Address of mortgagee or contract seller(number and street city,state,and LP code)
Name of assignee or other owner or holder of mortgage Q ,i g - / T 3 7
Address of assignee(number and street dty,state,and LP code) D ra war NO
•
Does applicant own property in any If yes,what county? What Taxing District? Has this dedu
other county
cn'mIndi Yes El current ear? Card N0.
A person is not entitled to this deduction unless the.person has a balance on the person's mortgage c
recorder's office(indudvng any home equity line of credit that is recorded in the county recorder's o/b
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 correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
Signature(ow rS fu0name) Date(month,day,year)
x �; j1IQ Ie.
Fug resident address of applicant( ben and street city,state,and P code)
�C 32 9' At kle /, 'z, ST and
re%AKETo NI rd 17h.7D
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 Iwo and a half years and a fine not to exceed$10,000. - - —