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FOR DEDUCTION FROM ASSESSED VALUATION INDEBTEDNESS �Coo'�u�nwed
pp T.o.�wnttsYffhi Year
;2W State Form 43709(R13/10-15) (� l j� q ,
S`=7 Presalbed by Department of Local Government Finance 11LL AAA b/���LLLJJJ
INSTRUCTIONS: File M.rk
r
To be filed in person or by mail. FEBS -I." 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 propel is / -•. ty Auditor
•located on or before January 5 of the immediately succeeding calendar year j, jiPluTit. County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Au.'., 7..- Iljr
where the property is located during the twelve(12)months before March 31 of each year the .-•J-...t itT - •
ch
See reverse side for additional instructions and quu2awliifiiccattions.
Applicant(owner or contact buyer-see re f`a/�1 ISe side)
41144"2.1
T i District, Key number I legal description R n r number
y'�.� c -' .i, 41- 13 - .l-ov- oo3. 7L ,t - o - 8 O1 C 42
Acp.1 value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of s the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
O Sr o O o ❑ 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 different than that of applicant indicate below. Is the property in question:Annually Assessed
❑ Real Property 0 AnnualyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
6e4,1-- t —f /3�.-A
Address of mortgagee or contract seller(number and sheet city,state.and ZIP code) j" /1LE�rp At)Dt7e D
Name of assignee or other owner or holder of mortgage p j_l_L) ,.
Address of assignee(number and street city state,and ZIP code) /9-54
•
Does applicant own property in any If yes,what county? what Taxing District? Nas this deduction been requested If yes,state amount of deduction
other county on for
in Indiana? ❑Yes ❑No current year? ❑Yes 0 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 rt:
20 20 20 20 20 ' 20' 20
Signature of County Auditor County Date(month,day,yea)
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.
\ �S -1/,�I� k IM;I e- Date(month,day,yea)
or number and t � and coo'e) .
80aly v Ca - 4 � �70
Person authorized by duly executed Power of Atto or by IC 6-1.1-12.0.7 Date(month,day.yea)
Address of authorized person (number and street city,stale,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000. _