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�E m,P STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUAIO�p State Form 43709(R14/1-20) > dU ' ry 2.0 J
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'° -z, Prescribed by Department of Local Government Finance NJ
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INSTRUCTIONS: To be filed in person or by mail.
RECEWED File Mark
d '.-d� V F rm filed with:
Filing Date: Form must be completed and dated in the cale'hdar year for which the dedrEgtroA 4 s6u2/849 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. ❑ County Recorder
See reverse side for additional instructions./%d qualifications.
Applica (o r or contract buyer-see res r tions n revs ' )
1 i<? '1'
Taxing 'ct i Key number/legal description Record number Page number
Asses d va ue of al property=-of ortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
asse ment dat , rrent yea assessment date,current year date of application legal or q le owner?
(Jx Yes ❑No
If n ,what is his/her exact • e 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
Real Property ❑Annually Assessed
/// Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract sell/2/
Addres of mortgagee or contract seller(number and street,city,state,and IP code
Name of assignee or• -ky a ner or hol•- of mortggg� V /a ��
/ .gyp 9 l
0 //—%.1— e9 ,
Addre s of assignee nu ber/d street,city,state,and IP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other ty pp
in Indiana?coun ❑Yes III No current yeaerty for
r? ❑Yes ❑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 Audit° () _^ esi.,(3) County 1 Date(month,day yeah (�e���_�n�d`r` tSQY) CA — It— LJV -0
1/We certify under the penalty of perjury that the above and foregoing information is u and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
I Sighatu'ta(owl/u!name Date(month,day,year)
---: 7 k 5 � 9)- '26
Full esident address of applicant(number and street,city,state,and ZIP code)
'y71/71 s so_c, Owei ,AV e- Jai G(>A
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 years and a fine not to exceed$10,000.
CCEIPT FOR FILING STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
Na /�llirant'
eo yi / L ...4 Na7of mo a o ontr--t seller/
Date filed(month,day,yea Amount o)lebtedness axin istri
CA—`\--2O ZO . /d; Jed U1L
Key er/leg description
—��/tea — 9,.1.� id/ 20 Z,r�1 •
Signature of o ty Auditor/County der Coun i L
'Date(month,