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a. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION \
��- State Form 43709(R73170.75) if).-941\ .'-'-=' PrescribPrescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail. Form filed 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 CountyAuditor or County Recorder of the county where the s Auditor
located on or before January 5 of the immediately succeeding calendar year. ly Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of b
where the property is located during the twel a(12)months before 31 of eadt yearthe deduction is sought
See reverse side for additional instructions and qualifications. n c r :1 1 2018
ApW ( or contact buyer- restrictions on reverse side)
S ,N 1e� _ C 1 \t� . 6 4�
T District Key number I descri _ n�''t�t'1 `, Rerdi L.numtier;l ?;r Page number
— �° 202— OVl-•MAT-0 erJ)[�bill. ",�e Alr:- ' 7q
a 2�g� t 5
Assessed value of real p,upnrty as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness&eld as of Is the applicant the sole
m4e<rnerd date,current year assessment date,current year date of ap lication legal o uitable owner?
ri) oCX) Yes 0 No
If no,what is his/her exact share of interest? If owned with tl2n spouse,utdicaie with whom II �\
If name on record is dulerent than that of applicant,indicate below. a property in question:Annually Assessed
Real Property 0 Mntral yAssessed
• J� I Mobile Hoare(IC 6-1.1-7)
Name of mortgagee or contract seer ---Th
Address mortgagee or contract seller(number and street city,s�i'e LP e)o�� / •�� C� S-h-e
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? Wnat Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes 0 No current year? ❑Yes ❑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(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 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.
fgnatur owners full name)<�
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 Iwo and a half years and a fine not to exceed$10,000.