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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Tnship ;Year
FOR DEDUCTION FROM ASSESSED VALUATION State Pam43709(R13!10.1 S) •
*- Prescribed by Department of Local Government Finance '
INSTRUCTIONS: _ _ File Mark �'�
To be filed in person or by mail. Fo fi with:
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 unty Auditor
located on or before January 5 of the immediately succeeding calendar year. County 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 sought
See reverse side for additional instructions and qualifications.
Appliant(owner
Mor ctobbreY sricdarsT�
IT Z/ 1' �Vr\�`f111r\ 1� ?�V�`}}(- `�' -M— l�+l `O W C..vs_-a �Key number/Inomolovrtinfinn RC7 CI t Ur Page ben
Assessed ramie of real property as of Mortgage I Contact indebtedness unpaid as of Mort � �l je�nerd data,currerd gage/Contract indebtedness unpaid as of Is the applicant the sole
year die,C renty2at 1 - date of application legal or equitable owner?
(_al4 a�LJ ❑ Yes 0 No
If no,what is his/her exact share of interest? I If owned with someone other than spouse,indicate with whom
If name on record is afferent than that of applicant,indicate below. Is the piuprriy in question:Annually Assessed
0 Real Property 0 AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller s--.T _ 1 , . FILED
Address of mortgagee or contact seller(number and street,city,state,and ZIP code)
Name cif assignee or other owner or holder of mortgage DEC A LOI8
Address of assignee(number and street city,stale,and ZIP code)
RIBSON ^ N(
Does applicant own property in any If yes,what county? What Taring District? `nag this dedo�'
onlQejRequesied If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes El No current year? ❑Yes 0 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
recorders office(ndudirg any home equity fine 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
kSignature of Coun y Auditor County - Date(month,day,year)
I 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
r 1 contract buyer of the aforementionedeJ/ � property on date application is tiled.
Sig net ) � k 8hd Date(month,day,year)
l2-1"-19
Full r . address of a t( m r sheet, state,and ZIP •e)
St S (a lbn s` - . oji,,in l Gij 311 �l366D
Person authorized by duly executed Power of Atiorrhy or by IC 6-1.1-12.03 Date(rrmnrds,day,year)
Address of authorized person (number and street city,stale,and ZIP code)
•
The penalties for perjury can include imprisonment up to two and a hat years and a fine not to exceed$10,000.