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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(Ri3/t a15) t-1°)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail. �0�9 Form filed with:
Filing Dates 1) Real Property.Must be completed and dated in the calendar year for which the deduction is SIuc�IIu 13
Must be filed or postmarked with the County Auditor or County Recorder of the county where tAe property is County Auditor
located on or before January 5 of the immediately succeeding calendar year. Lel' 03eounty Recorder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor o e
where the property is located during the twelve(12)months before March 31 of each year the tilea1 P
See reverse side for additional instructions and qualifications. (1N G
Applicant(owner or contact buyer-see on reverse side) GNP.
a.(1C..l.S 4- C 0\,u,n SO 4 NM t V
T . g District Key number I leg atdEsaiption Reavd nu Page um r
kr'tn<eA-OC1 al_Q -la -OOO - tO4- oDD - yga- OaR �:01 qQ
Assessed irate of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as milt
Is the applkam the sole
as�^=nent date,aurent year assessment dale,current year date of appl I legal or aq
S
ow someone' es ❑ old
If no,what is his I her exact sham of interest? If wined with ometh)an��lo with whom
If name on record is different than that of appft ant,indicate below: Is the in question:Annually Assessed
`WN\aW%mortgagee or contract seller r2 V J 73 .
Address of morn ee or couhml seller(number and street,city,state,and ZIP code)
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? What Taxing District? Has this deduction been requested it yes,state amount of deduction
in�Indiana?county ❑Yes 0 No curren on t year?or ❑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 aedit that is retorted in the county recorders 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 p perty on date application is filed. R.
Signawr (o fish's lu���`� rr�)� Date(rob — I leyea0
Full resident address of t(nu d ,state,and ZIP code) c, ` ��
1 O �fY o —f Q Q0 l vac r --Qr c \ 1\AL
Person authorized by duty ex ed P r fAttomey or by IC 6-1. 2-0.7 ) l Date(month,day,year)
Address of authotaed 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$10,000. _