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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township g IC�
Year
FOR DEDUCTION FROM ASSESSED VALUATION � d\ 1
�" State Form 43709(R13!10.15) �J� ` "ro V WJ
Presrnbed by Department of Local Government Finance 0�1J�1
INSTRUCTIONS: File Mark
Tb be filed in person or by mail Form filed with:
Filing Oates: 1) Real Property.Must be completed and dated in the calendar year for ntidl the deduction is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the properly is County Auditor
opted 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 durig 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 contract buyer- on reverse side
Q k � \%.
aL
T D" Key number/legal desolationR n r Page nu
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Assessed value of read property as of l- IL' 1-1/4 CO -Oa :Sig -023 •
Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indeb>.r ess pa as f th. 1.-nt the sole
assessment date,cutest year assessment date,current year date apqp moron^ 1� r'u'dabde owner?1OV--• II Yes ❑ No
If no,what is his/her exact share of interest? If owned withIrneone olh r than spouse,UMAO tth 2019
If name on record is different than that of apprcant,indicate below: pm m W tiort nuai sensed
wally Assessed
g e Hare(IC 6-1.1-7)
Name of mortgagee or contract seller r 11
Address of mortgagee or contract seller(number and t city,state,and ZIP code) '
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street dry,state,and ZIP code)
Does applicant arm property in any If yes.what county? l Drawer O...(96/(., ed If yes,state amount of deduction
other county
in Indiana? ❑Yes ❑No / - No
A person is not entitled to this deduction unless the person has Card
a f'd N O. 53( /J !edness that is recorded in the county
:wader's office(induding any home equity fine of credit that r. "`---CCC sis for the deduction.
COUNTY AUDITOR
Deduction a in the amount of.
•
20 20 20_ 20 20 ' 20' 20
Signature of \pi
a Y1.1` County - Date(m �da). `'�}�'�{IJl
I/We ce ' under the penalty of perjury that the abov- - • .regoing information is true and correct and that the applicanti a re-4d nt'of Indiana and
owner i contract buyer of the aforementioned property on date application is filed.
Zit(owners filth na7 ncas
Date/ d ill
Full resident ad or applicant(number and t city,state,and ZIP code)
2\j Cent h)n— J'�l L\ v .
Person authorized by duly executed Power cI: m Attoey or by IC 6-1.1-12-0.7 DaN0 yp '
Address of authorized person (number and street dry,state,and ZIP code) L// 1` I
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000. -