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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION R0bk
1State Fonn43709(R13 r 10-15) � c w / 9
Presaled by Department of Local Government FinanceJIII `• I `� - °--cal I
INSTRUCTIONS: -2-22‘ — Go% —g' 6b- File Mark
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To be filed in person or by mail. Fo fi 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. County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is located during the twelve(12)months before Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant(9ener ppontrad see on reverse side)
0) s . °jCt 03°1 22573--- (M°611 Mt)
Taang[{gL''' Key number!legal�dddeeescriiption3 7 Record number Page number
Assessed property as of M�oStgage/Contract indebtedness�unpaid��of MortgageO I Conn indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of pl 1 C.a legal uitable owner?
anL Yes 0 No
If no,what is his/her exact share of interest? If owned with oth than spouse,indicate with whom
If name on record is afferent than that of applicant,indite below le e p.0 my in question:Annually Assessed
Property ❑ Annually Assessed 6
• Mobile Home QC 61.t-7)
Name of nnrtgagee or contract seller ��
21— �e�� e
Address of mortgagee or contract seller(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage F I l E I)
Address of assignee(number and sheet city,state,and ZIP code) JAN 18 2019
Does applicant own property in arty If yes,what countyr What Taxing District? Has this deductioattaen raga f- ,state amount of deduction
other county
cup r
Indiana?
in ❑Yes El No airrentyeeRk
A person is not entitled to this deduction unless the person has a balance on the person's most§�Ui RYrtlr ttrglac®degIdr recorded 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 of:
•
20 20 20 20 - 20 - 204 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.
Si re( nets me) Date(month,day,year)
(i„�i�Cu jail I �nd p 1 / f-20 - 1 q -
Full resident address of t _7 Napp6a" 3(nu 0 W street cry stairl r(d7JPalde) 3`rl- AcF G .
Person authorized by duly executed Power of Attorney or by IC 61.t�-12.0.'/ Date(month,day,year)
Address of audivriced 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 510,000.