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; STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
�,;:. FOR DEDUCTION FROM ASSESSED VALUATION "1
' State Form 43709(R13/10-15) \, cY\ 2°l q ,
% ,•eu%' Prescribed by Department of Local Government Finance g
INSTRUCTIONS: ?
County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the properly 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.
Ap
jli nt(ownerorcontra uyer- restrictions on reverse side)e .
Taxing District K n tuber/legal description Record number Page number
�” 6 —13-1(1-100 -00o .513-o0 Zro20 0Oq°°
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness3mpaid as of Is the applicant the sole
assessmentdate,current year assessment date,current year date pp)hi ^ ^Vv legal or uitable owner?
',lJ\7V1� • Yes ❑ No
If no.what is his 1 her exact share of interest? If owned with omeone othedthan spouse,indicate with whom
if name on record is different than that of applicant,indicate below: I property in question:Annually Assessed
[ Real Property 0 AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
---Name of mortgagee or con seller
FILLAddress of mortgagee or contract seller(number and street,city,state,and ZIP code) ,. .
Name of assignee or other owner or he DEC r 1 A .8 0
19
Drawer NO.., (90
Address of assignee(number and stre
Qq I i
6 I — NO �I 4b��q
Does applicant ownproperty in any Card i �r O. . B semi.
•t of r E ted If yes,state amount of deduction
other county b FZ
in Indiana? ❑Yes 0 No current year? ❑Yes Eli No _
A person is not entitled to this ded on's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any ho y recorder's office)that is the basis for the deduction.
ITOR
Deduction approved in the amount of: - -
20 1 f 20 20 20 20 ' 20' 20
Signature of MO County Date onth,day,year) t^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.
Signatu ow ers full name) Date(mo day, ar)
A. � Iel�
ul resid t address of licant(number d st ee ify,state,and ZIP code)KF
Person authorized by duty executed Power of Attoof Attdrneyor 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.