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zSTATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
jir State Form 43709(R1216-14) (�,1n.3�
,,, Prescribed by Department of Local Government Finance "✓M%%%
INSTRUCTIONS: File Mark
To be filed in person or by mail. 'NI h:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is soug ik
Must be filed or postmarked with the County Auditor or County Recorder of the county where the prope rat -°'.ty 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 yap' q et
where the property is located during the twelve(12)months before Mardi 31 of each year the deduction i �deehbtjjhF / 2019
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Ryan A. Lewis Janell M. Lewis
W 1 f 0, Taxing District Key number/legal description 26-05-01-200-003.789-017 2
G16s { 1/P per I
l
Assessed value of real property as of Mongage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the apRtcant the sole
March 1,arrera year March 1,current year daze of application legal or equitable owner?
138,900.00 49532.67 p Yes 0 No
If nor whatis his/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
IZI Real Property 0 Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
FARM CREDIT MID AMERICA FLCA
Address of mortgagee or contract seller(number and street,dry,state,and ZIP code)
1601 UPS DRIVE LOUISVILLE, KY 40223
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,dry,slate,and ZIP code)
Does applicant own property in any If yes,what county? Wnat Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes 0 No current year? ❑Yes ❑NO
A person is not entitled to this deduction unless the person has a balance on the persons 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 of:
20 20 20 zo_ 20 20 20
Signature of County Auditor County Date(mond,day,year)
w
I 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 owners fun n e) Date(month,day,year)
_ ` ,K , AAA-P.—a> 01/16/2019
Full re ' nt address of applicant(number and street,dry,state,and ZIP code)
6831 N. SR 65 HAZELTON, IN 47640
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and skeet,aN.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.