Mortgage_Fogg (2) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
E' ''e.- ' FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13110-15)
`— Prescribed by Department of Local Government Finance
INS7RUCTIONS: File Mark
To be filed in person or by mail. Form sled 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 of the immediately succeeding calendar year. /� County Recorder
2) Mobile I Manufactured Homes not assessed as Real Properly: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
See reverse side for additional instructions and qualifications.
Applicant/for contract buyer- son reverse side)
T . District description / Record number Page num r
/,?cxa C„'‘-7a-oil- mad-off efts- oa abet a
Aq«+acarl value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,currant year assessment date,current year date of application legal or equitable owner?
2Qr CO 6 ❑ Yes ❑ 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&ferent than that of applicant indicate below: • property in question:Annually Assessed
Iseal Property ❑ Annually Assessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee Or contract seller f j t
Address of mortgagee or contact seller(number and street city state,and ZIP code)
(g �
Name of assignee or other owner or ho Sr rtgage / / ! / A
t,
Address of assignee(number and street, • te,and ZIP e BAN ?
?019
Does applicantown property in any If yes,what county? ---- --
oust If yes,state amount Of deduction
other county 0
N Indiana? ❑Yes ❑NO /
A n is not entitled to this deduction unless the Drawer 11r O• o.l f
person pNed in the county
recorder's office(including any home equity fine of a '•'''•.'••• basis for -
Card .NO. .....Deduction approved in the amount of
i 3- I� -. 01 ooq
'20 20 20 I " I 20' 20
I
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 I contract buyer of the aforementioned property on date application is filed.
Signatu�ve✓full name) Date(month,day,year)
-Full residQri aQCress of applicantbet and a;.wet,city,atete,and ZIP code)
7V 7 .6 coo.tt... ST, OYiwe .eTd+r-t_
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 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 two and a half years and a fine not to exceed$/0,000. .