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STATEMENTFOR OFDEDUCTION MORTFROM GAGE ORASSESSED CONTRACTVALUATION INDEBTEDNESS County Township Year
State Forth 43769(R13!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 Mardi 31 of each year the deduction is sought
See revs side for additional instructions and qualifications.
Applicant her orcon��buyer-se�,e�onreverse
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T - Key udm/legal description l/ Record numbpx.t. Page number
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Assessed value of real property as of Mortgage!Contract indebtedness unpaid as of Mortgage I Contract indebtttccedddness unpaid as of Is the applimrd the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
El Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other than'spouse,indicate with whom
If name on record is different than that of applicant,indicate below: .I-s thet property in question:Annually Assessed
�1LI Real Property 0 Annually Assessed
• �/� � / Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller 7/2.44 - / � /`..r.(f eiAddress of mortgagee or contract seller ber and street state,and ZIP 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 It yes,state amount of deduction
countyother in ❑Yes ID No curenpnt yeeaar?w ❑Yes ID 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 20 20 20 ' 20' 20
Signature of County Auditor County Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner!contract buyer of the aforementioned property on date application is filed.
Signature((owner's I O
(0/ y Date(month,day,year)
Full resident of t(number city, and LP code
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Person authorized by duty exeeaneddPPower of Attorney or by IC 6-1.1-12-0.7T 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 Iwo and a half years and a fine not to exceed$10,000.