Mortgage_Clay NE %o, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
LA*•,�[?����Qr;\ FOR DEDUCTION FROM ASSESSED VALUATION
lyir g ` .1 State Form 43709(R 13/10-15)
kfsie `" Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail. Form feed with:
Filing Dates: 1) Real Properly: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. t y
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor e u i•
where the property is located during the twelve(12)months before March 31 of each year the ded ion i _:ghti I�t my Recorder
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side) /� DEC 2 7 2018
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Taxing District Key number/legal description Re' rd nu I- r Page n..mber
0b- la - 0-7 - aOl -001 , Rag -®ak ,e ft id,
Axwssed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract ingtieVA ugggq frT pt,' t e3gp( a_� ,he sate
assessment date,current year assessment date.current year date of application
`0I'�J�`r V U14 I V '§aLei dkt1iAde owneR
Sg / 1 3, co ai Yes ❑ No
If no,what is his/her exact share of interest? If owned with someoni other than spouse.indicate with whom
If name on record is different than that of applicant,indicate below' Is the property in question:.Annually Assessed
['Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
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Address of mortgagee or contract seller(number and street,city.state.and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state.and ZIP code)
Does applicant own property in any If yes,what county? Vvhat Taring District? Has this deduction been requested If yes.state amount of deduction
other county ��� on property for
in Indiana? ❑Yes GNo current year? ❑Yes CI 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
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 foreooirg 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.
Signature(owner's full name) Date(month,day,year) •
`r' ..%t_ C
Full resident address applicant(number and ee:,city.state.and ZIP code)
S3-I N . t'cince Si. 1 Pcinee4-on icI 1.11V10
Person authorized by duly executed Power of httom y or by IC 6 L 1-12-0 7 1 Date(month.day year) 1•
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 S 10.000.
RECEIPT FOR FILING STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
Nam f applicant Name of mortgagee or contract seller 'Ur
Dated(month,d- ,year) .Amount of indebtedness . O Taxing District
Sergi-3: - DEC 2 7 201C
Key number/legal description I
Signature of County Auditor I County Recorder Coup/��- !Date th,•da 8
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