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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township
• Year
FOR DEDUCTION FROM ASSESSED VALUATION State Form 43709(R14/1-20)Prescribed by Department of Local Government Finance 0�)
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. i! County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is A
located on or before January 5 of the calendar year in which
,AppFcant(owner or c ntract b re rictions on reverse side)
Taxing Distri 3 tuber/I I cription Record numb Page number
Assessed valu of real property as of Mortgage I Contract indebtedness unpaid as Of Mortgage/ ontract indebtedness unpaid as of Is the ap li nt the sole
assessment date,current year assessment date,current year date of a !cation A,J ,a,legal ore !table owner?
es El No
If no,what is his/her exact share of interest? If owned with som one other than spousejinate with whom
If name on record is different than that of applicant,indicate below: Is t property in question:Annually Assessed
❑ al Property ❑Annually Assessed
• Mobile Home(IC 6-1.1-7)
Name of mortga or contra seller
IIIIICC L am/
Address of mortga ee or contract seller(number and street city,state,and ZIP code) �'(n�
Name of as
-- S1Cn2i—CU2U
DIp / 9 at91
Address of
Drawer NO iIBSON COUNTY / eiTOR
Does applic ang District? Has t !s aucuun been requested If yes,state amount of deduction
other count on property for
in Indiana? current year? ❑Yes ❑No
A person is Card NO. ince on the person's mortgage or contract indebtedness that is recorded in the county
recorder's Jed in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction r.,,.. -
20 20 20 20 20 20 20
1
Signature of County Au 'o ` t i\ )(=�3 n County \LS Date(moday/ear
I/We certify unde a penalty of perjury that the above and foregoing information s true and correct and that the applicant i a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
:.(owner's full ram,) Date(mo th,da ye
! re..kentaddres- p!cant(n/ n4çci .t state,and ZIP code) ('](ctic
Person authorized by du y execut d Powe 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.