Mortgage_Obert (3) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
l' State Form 43709(R 13/10-15)
`- Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail Form fled 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.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county 0 County Recorder
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant(owner or contrail Boyer-see restrictions on reverse side)
r (( — a-. Net-\P.\ss c_ r-k-,Taxing District Key number/legal description 1e p r/
'1-Air O \•. ra S -a u-moo-Do a . ti3•k-Q:D 9 Recad nnl � u It `.
Assessed value of real property as of Mortgage I Conti-act indebtedness unpaid as of Mortgage!Contract indebtedness unpaid as of Is the applicant the sole
assessment data,aurerd year assessment date,current year date of application CO legal or ,�y equitable-esle owner?S I S U Cap, Onn ❑ No
If no,what is his/her exact sham 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
�'�yy- in Annually Assessed
nuable H Assessed
/'� � G'� �, (� /'� �� �/ `��^,/i Ile Home(IC&1.1-7)
Name of mortgagee contract seller�/' ` O r,r ]JC L __AJ . -0� �9
Address of mortgagee or contract seller(number and street city,state,and ZIP code) �1 %�'O
0 1 QB
Name of assignee or other owner or holder of mortgage 1 tlr 'l
-a ., PVOI
Address of assignee number and street ' l��
g ( shy state.and ZIP code) ,������ N GQ��
Does applicant own property in any If yes,what county? Wnat Taxing District? Has this deduction been requaeted5QIf yes,state amount of deduction
other county
On�tea for in Indiana? ❑Yes ID No current ❑Yes ❑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 of
•
20 20 20 20 20 • 20• 20
Signature of County Auditor County • Date(month,day,year)
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
er I contract buyer of the aforementioned.property on date application is filed.
te(month date,
/S I ��/ �3 -Meiyea1 cli
Ruff el:t aDdress applicant(n and street state,and ZIP code)
—1y\8 S . o • \ I-.(jra' — . .
Person authorized by duty executed Power of Attorney or by IC/6-1.1- -0.7 Date(month,day,year)
Address of authorized person (number and street city,sale,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed S 10,000. -