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a< STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
�� FOR DEDUCTION FROM ASSESSED VALUATION
�' State Form 43709(R13/10-15)
^ Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
lb be filed in person or by mail. Qy' rm filed with:
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought .1( 11�0❑
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is � \t as:editor
located on or before January 5 of the immediately succeeding calendar year. rder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the oougtli/)i,
where the property is located during the twehe(12)months before March 31 of each year the deduction is sooghl 3
See reverse side for additional instructions and quafdications. 0 2018
t(owner or contract bpgr-see reab,Aaaa on reverse side) Gf
e.�ky 1 6 k Q.t r SSQN
Taring District Key number/legal description • • ,•.�r Page numbr
CQ‘1/4-k vs_b ,Q a11)- 13-\\ -Lk C O - l.=31o. LA LDS.(1) (O. 20i�A00•ro 1ct e
` .
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the apPlignt the sole
assessment date,courant year assessment date,current year date of application ammo legal or equ a owner?
�/r co Yes ❑ No
If no,what is his/her exact share of interest? If owned with someoneeoott�r than coo
indicate with w o r
If name on record is different than that of applicant,indicate below: is the property in question:Annually Assessed
0 Real Property 0 AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Na f mortgagee or contract sqer
•
Address of mortgagee or coed seller(number and street,sty,ste,antkaPcode)W Drawer NO
Name of assignee or other owner or holder of mortgage `�/- ^
Card NO. / (1 /4
Address of assignee(number and street city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? ---------..
ainnlInder tea? ❑yes ❑No current on tyyeea for ar? ❑Yes 0 No I _ -
A person is not entitled to this deduction unless Ore person has a balance on the penson's mortgage or contract indebtedness that is recorded in the county
recorder's office(induding any home equity tine of credit that is recorded in the county recorder's office)that is the basis for the dedrabom,
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/contract buyer of the aforementioned property on date application is filed.
Signature.( e) p � Date(month,day,year)
�/��y�/�'�G i
F rr ' ad�fxant(number and street city,state,and ZIP code)
1177s ,05o t Okla*Ad 6/{ r 4766n
Person authorized by duty executed Power of Attorney or by IC 6-1.1-1 -0.7 Date(month,day,year)
Address of authorized person (number and sheet 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.