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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
ounty Township Year
,. FOR DEDUCTION FROM ASSESSED VALUATION
Sate Fonn 43709(R13I 10-15)
`- 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 0 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 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.
Applicant(owner or contract b�j/rr--tsee restrictions on reverse side)
e X
ge number
�f1•1 ei Taeng District �� ram Key n• umber 19al � 1 oo-oco -8eio-oaf Record°� ` �H w4O .
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness r id as of Is the appli ant the sole
accectment date,arrant year assessment date,current year date of aaonte irei ;-� OJ_ legal or,eequit�able owner?
4 9 o ODD , lid' res ❑ No
If no,what is his I her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is alferent than that of applicant indicate below. Is the property in question:Annually Assessed
❑ Real • .,.. & • nuallyAssessed
Nacre of mo ea or contact seller
... .. Home(IC 6-1.1-7)
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage SW
tiii 1�R
Address of assignee(number and sheet, �� N
sg city,state.and ZIP code) GOON-(`(
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been retro If yes,state amount of deduction
other county in ❑ �pneaR ❑i Yes El No current 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
recorder's office(mduding 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_ G / 8 - 171- S T O -
Signature of County Auditor County .
• Drawer NO
I/We certify under the penalty of perjury that the above and foregoing information is true and cc --
nrrr1l1��net I.contrail buyer of aforementioned property on date application is filed. Card O. _
eY s rug na rr /
. r . bex I
WI resident ad applicant bend set,aty,state,and ZIP code)
X /5(og C gE7v > fle
• 13c &ArAt. 47G4g
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Daate(month,day,year)
Address of authorized person (number and street city,state,and LP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000. •