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.� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
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•
r Slate Form 53709(R13/10-15)
• e Prescribed by Department of Local Government Finance -
INSTRUCTIONS:
To be filed in person or by mail. File Mark
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is soughth:
Must belled or postmarked with the CountyAuditpr or County Recorder of the county where the property ro ert is F0 N=_dun
located on or be fore January 5 of Me immediatelysucceeding calendar year. y County Auditor
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. 0
'County Recorder
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side) — ! I Q�
V� L/ a'Ai: �,• • • •- _
Taxing District (-t-/� Key nu her legal description 17 �6 1�•.• 411 C�
f I As, si I a � 2 1 - t Record number E-ate Zip- • • OD-�(7.7 -� - -a .II as_
eap
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,current.year assessment date,current yearYet�teo�
date of application legal cr equitable owner?
If no,what is his/her exact share of Interest? arc
• 2 r 0•0
If owned with someone oth-r than spouse,indicate with whom es 0 No
If name on record Is'different than that of applicant,indicate below:
Is the property In question:Annually Assessed
Name of mcrt a c;contract seller Od Real Property O Annually Assessed
mortgagee Mobile Home(IC 6-1.1-7)
Evgnsvitle , che,rs
Address of mortgagee or contract sage; number and street,city,stale,d�Z/P code)
LAI 0 r
SVI Ile NI 715
Name of assignee c;other owner or holder of mortgage
Address of assignee(number and street,city,stale,and ZIP code)
E_ -
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction he qt. ,
other county ,6-d�'fJ/
it Indiana? ❑Yes p on properly for udtal dedoolidd
urrent year? OD
A person is not entitled to this deduction unless the person has a balance on the person'sc mortgage r contract indebtedness that is recorded in the county
recorder's office(including any home equity fine of credit that is recorded in the county recorder's office)that is the basis for the deduction.
Deduction approved In the amount of: COUNTY AUDITOR
1
20� 20 20 20 20 I __ 20
Signature of County Auditor 20_
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.
Si ture(comets&gnome)
Dale` (month,day,year)
�Ulc r FuVresident a .Tess cf applicant(nu er':nd •reef,city,state,and P code) D
70
r-i- /Al
Person authorized by duty executed Power ofAttorne Y YIC 6-t.1-12•p.7 /
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Date(month,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 half years and a fine not to exceed S10,000.
RECEIPT FOR FILING STATE ph r Inc