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: STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15) -1NC..]]]� O\ `„1 2DPrescribedPresed by Department of Local Government Finance 1"�hCC ••' b 1
INSTRUC77ONS: 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 County Auditor
located on or before January 5 of the immediately succeeding calendar year. unty Recorder
2) Mobde I 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 is sought
See reverse side for additional instructions and qualifications.
Appliicapt(. or/c�ontract buyer- restrictions on revee side)
Taxing D'. .11_ , \ `_1W 11 Record number Page number
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I tract indebtedness un id as of Is the nt the sole
assessment date,arced year assessment date,anent year date of 11 legal or q ' ble owner?
Yes 0 No
If no,what is his I her exact share of interest? If owned with re Prig,
other ihah yrmo,indicate with whom
If name on record is different than that of applicant,indicate below. Is property in question:Annually Assessed
❑ eal Property 0 AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller g®
Address of mortgagee or contract seller(number sheet city,state,a °�e) A���
Name of assignee or other owner or holder of mortgage FILED
I Al 0 C ZO1n
Address of assignee(number and street city,state,and ZIP code) JU1`I V J
• r' . . mo,
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been• '�a,u�Nj1c IQ i f9 aTabJnt of deduction
other county on Property for
in Indiana? ❑yes ❑No current year? `LJ Yes No
A person is not en..-. • is deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office( •udi . ny home -••- line of '' that is recorded in the county recorder's office)that is the basis for the deduction.
ir
/ �f'rlU TY AUDITORDeduction approved t of W'
<� •
20 20 20 - • 20 20' 20
Signature of County Auditor County^``\ Date(r� day �r)9
I,We certify under the penalty that the above and foregoing information is trim and correct and that the applicant is res'ent of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
Signature(owner's hill name) vI Date(r ,day
adtl of t(number
dty,state,and LP code) l/'1
ttrOt
Sfiti` n i ,Vtl\ - 3C\
Person authorized by d executed owe Attorney or by 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. -