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�1 s r STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS luntyT wnship` �'* FOR DEDUCTION FROM ASSESSED VALUATION P Year
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I ..4-. ':;iI/�i State Form 43709(R14/1-20) 1_. n„w
,- Prescribed by Department of Local Government Finance �� �1�J� G(J
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. ❑ County Recorder
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer see restrictions on reverse side
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Page nu er
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Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year dateef application legal or equit le owner?
4/21 quo es ❑No
If no,what is his/her exact share of interest? If owned w tWsomeone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is the operty in question:Annually Assessed
eal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name o ortgagee or contract sellerA k
doint
Ad re of mortgagee or contract se er(number and street,city,state,and ZIP code)
Name of assignee or other owner or h floftotg:��r -T.
.. _ ._ ' DraWar NO
2-,
(.40
Address of assignee(number and street,city,state,and ZIP code) 514. •5 ,
�J�V 2 20 20 What NO. �,IIUII
Does applicant own property in any ' If yes, t count What Taxing Dist aunt of deduction
other county in Indiana? ❑ 111
Yes No
A person is not entitled to this deductio a -vow;7 has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any h omeo B Se f. Ct Q I 411=4 i 8c6rded 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
Signatur f ounty itor ii County Date(mont ,day,year)
���� lami��iL) 1 i on__ / ► �2o/- 0
"/�certify under the penalty of per)urij hat the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contr buyer of the aforementioned property on a application is filed.
y,
Signature(ow r name) Date(month,day,year)
it/2451 2c%'z�
Full resid d r of ca nu er d street,ci ,state,and ZIP code)
Per n 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.