Mortgage_Langham (2) , STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
'� State Form 43709(R13/10-15) 11 O,n 2.01C
Presalbed by Department of Local Government Finance , J1
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 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 hvelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
t towns,. see 'ons o reverse) \
iton
arypiptipn
rl T anumber er'° 30O -001 a? -02Rec ok ` •-Inn
Assessed value of real property as Mortgage I Contract i debtedness unpaid as of Mort gel Contract indebtedness unpaid as of Is the apWent the sole •
assessment date,current year assessment date,Current year app1 n .Kl legal or a owner?
ll �1nbl3QQCror. Yes ❑ No
If no,what is his I her exact share of interest? If owned someone oth6 than spouse,indicate with whom
If name on record is different than that of applicant,indicate bekm: property in question:Annually Assessed
Real Property 0 AnnualyAssessed
Mobile Hone(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and sheet city,state,and ZIP code) FILE ,%
Name of assignee or other owner or holder of mortgage
FEB 1 1 2019
Address of assignee(number and abed city state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction beep rgg jet d' nt of deduction
othercouny on property for CilBtorUN JNTY AUDITOR
in Indiana? ❑Yes ❑No cunent year? ❑Yes no 1
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 fine of aedit 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 ' 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 property on date application is filed.
Sig re( wner5 ruff
r�i e) Dat2Amonth,day,ye
L
X�i - 11 . 1 •
I Full resin/�delln�tt aatldr pplican(,(qulnber tl street Oyer 'code� n 4 9 f
Person authorized by duly executed Power of Auomey or by IC 6-1.1-12.6.7 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$10,000.