Mortgage_Hahn .�. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
zr,a_ FOR DEDUCTION FROM ASSESSED VALUATION
'— � +' State Form 43709(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 properly 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 March 31 of each year the deduction is sought
See reverse side Jt.•ditional instructions and qualifications.
Applicant(owner tract buyer-see renstricti s e e sid)
V
Tin nistyafb Key a /ber eI/ ph�/ 4C0 ,A 7-GO 2 Record numbe Page number
Assessed value• O ! nL as1 � )�+tV�`n'
-- property as of Mortgage!Contract indebtedness unpaid as of Mortgage!Contract.indebtedness unpaidd of Is the applicant the sole
assessmentdat= cu -ntyear assessment date,current year date of application (JO legal or equitable owner?
70 707 ❑ Yes ❑ No
If no,what is his/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: Is th roperty in question:Annually Assessed
eal Property 0 AnnuallyAssessed
�� /� ��/' itMobile Home(IC 6-1.1-7)
Name of mortgagee or contract selter�%' ' !. ‘ 204.1 ." ���y �9 l..✓Address of mortgagee or contract seller(number an t city,state,and ZiP code)
D`tn „.6.7.6 _
Name of assignee or other owner or holder of mortgage 1 7
0,0 2049
Address of assignee(number and street,city,state,and ZiP code) S�OA/ •
Co .
Does countyicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,startb- nt of-deduction
otherin Indiana ❑Yes 0 No current y�ear?r ❑Yes 0 No �O/i-
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 rrthe 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 ' 20t 20
Signature tyAudtorix.e..v.
County Date(month,day,year)
I/We certify under th 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.
Si atu a(owner's full namItcyt Date(month,day,year)
Ill
Full resident ent addr '•f applicantmber and street cilyi state ZIP code)
r. i
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)
The penalties for perjury can include imprisonment up to two and a half year's and a fine not to exceed$10,000. .