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STATEMENTFORDEDU
CTION OF MORTGAGEFROMASSESSED VAOR CONTRACTLUATIONINDEBTEDNESSlotship Year
State Fonn 43709(R13/10-15)
Prescnbed by Department of Local Government Finance
NU 30 2oihe Mark
INSTRUCTIONS: Z e. II e r a
To be filed in person or by mail. Form filed with:
Filing Dater 1) Real Properly:Must be completed and dated in the calendar year for which the deduction is lit • '
Must be filed or postmarked with the County Auditor or County Recorder of the oourr�(y}t1 re County Auditor
located on or before January 5 of the immediately succeeding calendar year. V'6SON OUNTY AUDI'TO County Recorder
2) Mobile/Manufactured Homes not assessed as Real Properly: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 sought
See reverse side for additional instructions and quaff 'ans.
r
n reve side)egal description Rewd number Page number
17 -61 -4-10-1 • oa, . ti49 -OZZ Zo/ 1145-6
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indeMedness unpaid as of Ls the applipm the sole
accewrent date,parent year _ assiTent d�rram year date of application legal or equitable owner?
Yes 0 No
b no,what is his I 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 belovr. Is the property in question Annually Assessed
eat Property 0 AnnualyAssessed
Mobile Home(IC 5-1.1-7)
Name of mortgagee tray seller .
Aidei
Address of mortgagee or contract r number antl city,sta ,and ZIP code) Q — -'//l/
Name of assignee or other owner or holder of mortgage `\4_�- 1 ri � i•
Drawer NO
Address of assignee(number and street,dry,state,and ZIP code)
Does applicant own property in any If yes,what county? What T wring DLstria? Fh Card
a t-d O• •••.•other
in Indiana? ❑Yes El No cu
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 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(owners rue name) Date(month,day,year)
`1�� 4
�residentn.po. Hof app a :ft:45tdrl: antl ZIP code jo / 7/c6/5
Person authorized by duly exerted Power,�or by IC 6-1.1-12-0.7 Date(month,day.year)
Address of auttnxized 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.