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a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
FOR DEDUCTION FROM ASSESSED VALUATION -�-
°• Form State Fo 43709(R73I 10.15)
Prescribed by Department of Local Government Finance
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INSTRUCTIONS: .. i ile i ail 4
p
To be filed in person or by mail. Fonn fileitstki
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 NV Counnty'Audi r
located on or before January 5 of the immediately succeeding calendar year. CCo6mpdtecorder
2) Mobde/Manufactured Homes not assessed as Real Roperty Must file with the County Auditor of the coun�w
where the property is located during the twelve(12)months before March 31 of each year the ded ctidd
See reverse side for additional instructions and qualifications. / °A/r.r
Applicant/; (owner or contract buyer
---seee restrictions on reverse side) -"IV*y`
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g District Key I legal desaipf;on Record n, er Page number
TVQ C Il -IS - (C I - oo\ , 5'�3 -- 0 —1 . i V/47 -
Assessed value of real property as of Mortgage 1 Contract indebtedness unpaid as of Mortgage/Contract indebtedness un as of Is the applicant the sole
asca s'nent date,current year assessment date,current year date of application legal or equ5blearmeR
4 1QS OIll , IB' 'es p No
If ru,what is his I her exact share of interest? If owned with someone other thAi spouse,indicate with whom
If name on reood is different than that of applicant,iMicate below. is the in question:Annually Assessed
Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Her rtgagee or contract seller I pp ,p \/ ,\{ ,\y e} '-"'-"-'�`
Address of mortgagee or contact seller(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
in Indiana? ❑Yes ❑No currrent�year?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 annoyed 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.
r r 1 \�0 I ) j ate— tlay,
F iesident address of pp g
umber. '-,-- city,state-and ZIP code) .
Personauthorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 2 Date(month,day,year)
Address of autlmraed 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.