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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
tel: FOR DEDUCTION FROM ASSESSED VALUATION /1 \ h
- State Form 43709(R13/10-15) I I1�3pl\ 1( _ L �1 e1
Prescribed by Departrnent of Local Government Fnance l`\J1 IQ-,IN•` �'yq!'(J\ l 1
INSTRUCTIONS: _ File Mark
b be filed in person or by marl. Form filed with:
Filing Dates: 1) Real Properly.Must be completed and dated in the calendar year for which the deduction is sought
Must be filed or pos marked with the County Auditor or County Recorder of the county where the properly 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 twelve(12)months before Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant(or�mer�oyrwnaac(buy TF on reverse-en
.
a •�ryq.Ti"�V�'/-��(/_.^A`�lp�J'Sn,'il W��_ '`,l rp`b-/g
T D ar- • O p�[O10 W• T 0 4 Record
zol Ir a?um .
Assessed value of real plweity as of 1Mortgage/Contract indebtedness unpaid as of Mortgage Contract indebtedness unpaid as of Is the ant the sole
assessment date,arts:t year I assessment date,current year date of legal or�" bee owner?
�� v , /� Yes No
If no,what is his I her exact share of interest? If owned with Bone oth crxwron,indicate with whom � �
It name on record is different than that of applicant,indicate below Is t�jje property in question:Annually Assessed
Real Property ❑ AnnuailyAssessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller ` _
Address of mortgagee or contract seller Ober and state,and code) nu
ZIP ` 1( Lt i
Name of assignee or other owner or holder of mortgage
MAR 2 8 7019
Address of assignee(number and street,dry,state,and ZIP code)
Does applicant own p ny If yes,what county? What Taxing District? Has this deduction ' ,state amount of deduction
other INndana?y ❑Yes No on
maQlB ,�pa AUDITOR
A person is not entitled thi deduction unless the person has a balance on the person's mortgage orcontract indebtedness that is recorded in the county
rec order's office(including an 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
County •
1-41C1CCD3n
I/We certify under the penalty of perjury that t 11 ve and foregoing information is true and correct and that the applicant s a resid n1 of India(oa and
owner I contract buyer of the aforementioned property on date application is flied.
i re(comets lull n e) Date month ay, ear)
—wi
n
W reeddont address of a t OW and sInet� state. XP}�4 r
authorized by duly executed Powe/of Altomey or by IC e-1.1-12-0.7 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. - .