Mortgage_Kleaving vt"'V STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
ie
;a.,_,_ ' FOR DEDUCTION FROM ASSESSED VALUATION •
State Form 43709(R13/10-15)
S „cr. Prescribed by Department of Local Government Finance .
INSTRUCTIONS: File Mark
To be filed in person or by mail. Form filed 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 D County 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. 7 /G / /g .
Applicant caner or contract buyer-see restrictions on reverse side) / I
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Taxing District Key number/lega cription Record number faeyys ru tr
F4- bran ch 21,9- 19 - 19 - IDI - 0o0. 13q -oat° -7011 000 173
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,anent year assessment date,current year date of a plic ryryation legal or equitable__// owner?
t "(O, 40y Erces ❑ No
If no,what is his/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 below: Is thy property in question:Annually Assessed
IR'Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller •MOrfia Tat+P,Ii (k Indid00 IOC./ 1SA-0A-
Address of raingalger or contract seller(number and street.city state,and ZIP code) 7 / 7- IL E
502- 0,ioss Poi/i- Rivet EI<!/"ux.itJille, w
Name of assignee or other owner or holder of mortgage qr1
Address of assignee(number and street,city,state,and ZIP code) DEC 8.J Z018
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requeste• If - ,: i•ount deduction
other county on property for r -i1d77G':
In Indiana? §)�,s • cnUNTY AUDITOR
Yes No current year? ❑Ye [!.
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contras 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/contract buyer of the aforementioned property on date application is filed.
N. Si ature(owner's full name) Date(month,day,year)
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Full resident address of applicant(humber and street,city,state,and ZIP code) •
305 t cot,S+er' c-4 For- gx-ckneAm \ \ 4-7 (042�
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7- Date(month,day,year)
Address of authorized 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.