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.M -"-"*t STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE Townshi Year
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FOR DEDUCTION FROM ASSESSED VALUATION /R— '
"\.t'.>_-'1+ State Form 43709(R14/1-20) it 7
``.re `/`* Prescribed by Department of Local Government Finance l
0 OZ.® S AO ile Mark
INSTRUCTIONS: To be filed in person or by mail.
Form -d with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sou h t p g E County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county wh.-- .a Qro erty i T '4ta
located on or before January 5 of the calendar year in which the property taxes are first due and pale. County Recorder
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on v rse side)
Taxing District Key number/ egal description Record number Page number
a 24 a , -/q-10 -aoJ -000. 57g -007 n? b ,2O .5YE ?
Assessed value of real proper l as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current ye.y assessment date,current year date of application legal or qui le owner?
57 no 3 es ❑No
If no,what is his/her exact share of interest? If owned with someone other tl{an spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
?teal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller . /J
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage �j
Address of assignee(number and street,city,state,and ZIP code) / () 0(') Cj
Does applicant own property in any If yes,what county? I What Taxing District? Has thin D •
T ✓ / D9
/
other county on prop I-a l?'E I' N O
in Indiana? Ill Yes 11No current
A person is not entitled to this deduction unless the person has a balance on the person's mortg
recorder's office(including any home equity line of credit that is recorded in the county recorder Card NO.
'COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor County Date(month,day,year)
A/
I/We certify under the penalty of perjury that the ab a and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned prope on date application is filed.
c.,.Sriiure Iv ers full na Date(month,day,year)
tkit
ull resident addre of Want(number and street, 'ty,st, to and ZIP ode)
(oar � n?��«, s - c��.�e�` �,� , /.� 1r�le 0
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 oeriury can include imprisonment up to two and a half years and a fine not to exceed.Rlo_nun