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, STATEMENT OF MORTGAGE OR CT
✓ 3,V . FOR DEDUCTION FROM ASSESSED VALUATION INDEBTEDNESS County Township Year
T^ State Form 43709(R13110-15)
^ Prescribed by Department of Local Government Finance
INSTRUCTIONS: • File Mark
To 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 which the deduction is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is 0 County Auditor
located on or before January 5 of the immediately succeeding calendar year. 0 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 Merritt 3f of each year the deduction is sought
See reverse side for al instructions and qualifications.
Applicant(owner or twyer-see • on rse side)
r
District(....in
n.I DDI K,ey/1/�ym_ ! al pipfiom ,/ �/—f �1 Record number nu
rR�^ real P !�� - / 9��• /ntract0- OO.as of 6P 1 9age/Contract ocdf indebtedness unpaid , Is the applicant
assessment date,c urent year assessment date,current year date of appin legal or equitable owner?
0100 ❑ Yes CINo
If no,what is his 1 her exact share of interest? If owned with someone othefthan cpoiza,inchoate with whom
d name on record is different than that of applicant,indicate below: Is property in question:Annually Assessed
Real rty ❑ Mobile
e(IC
O ��cc f� Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number ands 4 city,slate.and ZIP code) • I, a
Name of assignee or other mtraQr,�r bolder of r(gag e rF7,9 y L ��II
v"u� pia �,� _ V?�19 a
Address of assignee(number and t city,state,and ZIP code) SON
COI/ •, ji
y1
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yesj!fate amount of deduction
imnindia a?� ❑Yes 0 No currrent yea?property for ❑Yes 0 No `ram/TOp
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 rice County - Date(month,day,(rear)
I I certify 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 file.
�Sltvinit,u{r//e�( lull name) / 1 TiDate(month,day,year)
Ful recant r IK— rf mbar and sheet,day. g and ZIP code)
'�' t� 6k Sk l vv-emvIth ,N�.1
Person authorized by duly ex-• r-tl Power of Attorney or by IC 6-1.1-12-0.7 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. -. -: