Mortgage_Thoman c. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
L.l}.t FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
�-• Presalbed by Department of Local Government Finance INSTRUCTIONS: f J'�
1 Fd; `r1 with:
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To be filed in person or by mail. ,� Form
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought �I
Must be filed or postmarked with the County Auditor or County Recorder of the county where the proper f PR 2 3 J9County 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 March 31 of each year the deduction' ught d .i
See reverse side for additional instructions and qualifications. �I , --.jm111r
Applicant(owner or contra -see restrictions on r ) GIUSON COUNTY AUDITOR
Taxing District description
' 0ter 1 Page
mber la- lgDL(- Q03. 3IS- �q,S .
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appicant the sole
assessment date,aarera year assessment date,anent year da �l legal or equitable owner?dQl)v ❑ Yes El No
If no,what is Ns I her exact share of interest? If owned with someone other than spouse,indurate with whom
If name on record is different than that of applicant indicate belay. Is the property in question:Annually Assessed
❑ Real Property 0 AnnuallyAssessed
• Mobs Home(IC 6-1.1-7)
Name of mortgagee arcontrad seler ��'](��.'��'��
Address of mortgagee or contract seller(number and street.city,state,and Z/ 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 If yes,state amount of deduction
other county on perty for
in Indiana? ❑ pro Yes ❑No current year? ❑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 A 20 20 20 20' 20
y
Signature of Auditor , p r County - Date(month,day,year)
I/We certify under the penalty of perjury that the above
bove 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.
Signal:Timers hull name) Date(month,day,year)
X. ' A . 4 — y -a3 - i9
Full esug applicant number andMaty state.
1/L ZIP cpde rt 4 7 0
Person a l PA
aauthorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 _1�VI_ -1
IDate(month,day,year)
Address of outhunted bed 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.