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n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
-,• . FOR DEDUCTION FROM ASSESSED VALUATION
.. =,.�'. State Fonn 43709(R13 f 10-15)
Ste-/ Prescribed by Department of Local Government Finance `��
L J File Mark
INSTRUCTIONS:
To be filed in person or by maiL m1 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 County Auditor
located on or before January 5 W the immediately succeeding calendar year. County Recorder
2) Mobde/Manufactured Homes not assessed as Real Property:Must file with the CountyAuditor 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.
owner or contract b `-'see re son reve •
�1\ mhmber! 6 2 Record mum r Page u ber
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Assessed value of real property�of '6 ' I\ age) indebtedness�O k �D Mortgage//ConO indebtedess unpaid �o lithe applies �sole assessment date,date,current year assessment date,current year date of i anon __legal or equitable owner?
l \ OF
❑ Yes 0 No
If no,what is his f her exact share of interest? If owned with someone other than spouse,indicate with whom
\ /
If name on record is different than that at applicant,indicate beta- property in question:Annually Assessed
\Real Property ❑ AnntrallyAssessed
J / . 1 Moble Home(IC 6t.1-•
7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller( `ry'I coo tc/ T79 ®p
Name of assignee or other owner or hold I / n F I L "by
Drawer NO LX Address of assignee(number and street, ! DEC q A 1 LU I(S
Card NO, 93 I
Does applicant own properly in any If is deduction bee S uestdr� If amount of deduction
otin Indiana? ❑Yes ❑No I ,---- ywb xa .;11-;7o_�r
t tx„
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract mdeb'fediress'tliat is��'orded 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.
COUNTY AUDITOR
Deduction approved in the amount at
20 20 20 20 20 ' 20' 20
Signature of County Auditor County Date(month,day,year)
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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.
ire(owner's full
X S _iM OufiThW� PnP —7(����tt} ° 12�'21- h '
F . ad pplxan jnucA�rsty ypre gird ZIP aQ2J^M^��VI —� 1 " I V
Person authorized by duly executed Power of Anomie,/or byyIIC�6-11`.1-1'2-0.7tY/Y.- 1 / Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)
The penalties for penury can include imprisonment up to two and a haY years and a fine not to exceed$10,000.