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V , . STATEMENTFORDEDUCTION OF MORTGAGEFROMASSESS OR CONTRACTEDVALUATION INDEBTEDNESS County Township Year
:'' State Form 43709(Rf 3!10.15)
�-' Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail. Form filed with:
Filing Dates 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. 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 is sought
See reverse side for additional instructions and qualifications.
Applicant(owner or buyer-see restrictions on reverse side)
3')all /neon, - . Stall,)n s number Record
Troopg District . Key e number
abu- 24'- i/-o7 yao , LW/. 9/f 0040 7 o 9 3�'82
Assessed rake of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equ owner?
y/N/29,000 Yes 0 No
If no,what is his I her exact share of interest? If owned with someone other than spouse,inchoate with whom .
If name on record is different than that of applicant,indicate below Is th�pert in•, �;nually Assessed
LN'K--. ' ;l % af)yA55e(sed
- � .i,-Home(IC 57.7-7)
Name of mortgagee or contract sellerlll ' f/U.
Ad (L>� ordress of mortgagee L.�PUS(_/(number contract seller IJ� state.and ZIP code) t�"� Q 'lD\9
Name of assignee or other owner or holder of mortgage P sti/ S 0121'
Address of assignee(number and street city,state,and ZIP code) ON C
GtBS OJ
Does applicant awn property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes El No current year? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mar yaye 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
Sig re f County AuQ"rtonr �'^ County Date(month,day,year)
�ejvu U,L6 r h s aY— 5=z8-i9
I/ e certify under the penalty of perjury that above and foregoing information is true and corned and that the applicant is a resident of Indiana and
er/contract buyer of the aforementioned perty on date application is filed.
Signature(owner's full name) Date(month,day,year) _
Fug�esident address of applicant(number and street dry,state,and ZIP code
55 S. 12.2.5 t • Vakland code)
1 .9 t7660
Person authorized by duly executed 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)
�( J '1
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000. cl N_