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�1-71. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
t��"jam.;4 C�unty Townshi z--8p Year _
•- \y FOR DEDUCTION FROM ASSESSED VALUATION
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7 / State Form 43709(R14/1-20) nk
-:' )< Prescribed by Department of Local Government Finance
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File Mark
INSTRUCTIONS: To be filed in person or by mail.
Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is
located on or before January 5 of the calendar year in which the property taxes are first due and payable. ounty Recorder
•
See reverse sid-or additional instructions and qualifi .tions.
Applicant(ow -r o contract buyer-seer riction one side)
axi strict 'number/ gal desc' lion Record num r Page number
r, i -/ -/Y?o�-.�/ og•J-,tea 20 . I A)
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant
assessment date,current year assessment date,current year date,of appli legal,or equitable owner?
O ❑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 the property in question:Annually Assessed
. I�1 Real operty ❑Annual Assessed
Mobi•le ly Home sse(IC 6-1.1-7)
Name of mortgagee or contract seller?-/v /
% it
Address of mortgagee or contract seller(number and sttrreeeef,city(`/state,and ZIP code) p
.46)*
Name of assignee or other owner or holder of mortgage __ - ��V 2,0 —�
Address of assignee(number and street city,state,6aD •�(1 zi., �O�o co
Does applicant own property in any If yes,what cc :en requested"Jtfly , tate amount of deduction
in Inds ounty ['Yes ❑Noark-CA-t IL:Q� Yes ❑No ii&Olr
in Indiana?
A person is not entitled to this deduction unless ract indebtedness that is�rgtfiYded in the county
recorder's office(including any home equity lin it is the basis for the deduction.
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature y Auditor County Date(month,day,year)
____&
I/We certify under th(penal y of perjury thbove 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 fu e) Date(month,day,year)
s-----
Full rent ad ress of a plicant u ber treet,city,•tale,an, r \ /� ��
• Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 / /�^C, O 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.