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San STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
•;_ State Form 43709(R13/10-15) 11730 n
Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail Form fi :
Ring 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 County Auditor
located on or before January 5 of the immediately succeeding calendar year 0 County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the properly is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Taxing number/legal descri n Page number
Fi- Yancin. 6 -ty-.1s=Loy - pbo- --02-6 b 43 ?I
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract innddl/ebte0dness)(maid as of Is the II the sole
ac.ac.mem date,comfit year assessment dale,parent year date of imtgrf ^ (r' Iegal w Yes ❑ ON
d no,what is his/her exact share of interest? u owned with someone oth/ueyumrt,Yf°r:J L,1p ra spouse,indicate with whom
If name on record is different than that of applicant indicate below property in question:Annually Assessed
Real Property 0 Annually Assessed
'vw_� Mobile Home(IC 61.1-7)
Name of mortgagee or contrail seller
lAddress of mortgagee or contract seller(number a a city,state,and ZIP code) FILE i,
Name of assignees other owner or holder of mortgage NOV 3 0 2018
Address of assignee(number and street city,state,and LP code)
lintu
Does applicant own property in any If yes,what county? What Taxing Dish-lift? Has this dothmseIQalT) ug$®!J 7%esA3 t of deduction
other county in Indiana? ❑Yes ❑No anent year? ❑Yes ❑No
A person is not entitled to this deduction unless the f---- -`-'---- --"----- "— ebtedness that is recorded in the county
recorders office(including any home equity line of c /^ \� �'/,Ll basis for the deduction.
Deduction approved n the amount of \\ /D I":l\\'C I' NO s� 0(�
20 20 20 Card NO. L4% `" ( 20 20
Signature of County Auditor Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and coned and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
�J S owner's a%S Doe jrgsh ) ' ,
'k\ ull resident address of applicant(number and street city,State,a ZIP cod I I
20o W tDo9nu—
Person authorized by duly executed Power of Attome)or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authaiired 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.