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�t,'fn„e.. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
"+ Iry State Form 43709(R14/1-20)
e a'e 1 Prescribed by Department of Local Gbverrithent'Firiance
. _ File.Mark
INSTRUCTIONS: To be filedin 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 p erty is
located on or before J ua 5 of the calendar year in which the property taxes are first due and p a ❑ County Recorder
See reverse side for additional instruction and qualifications. LE ;. ,
,
Applicant o Oeptir contract buyer s strictions on rev e side)
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Taxi.• II rict / e n m er/legal description �/�/ Recor4u� Page number
e G -// /rD -ood. %/�-D�9 , �d , o�//A
Assessed va ue o real ertyas of Mortgage/Contract indebtedness unpaid as of Mortgage/Contrac efitieefi ss'unpaid as of Is the applicant the able
assessment dat r ea assessment date,current year date of application .. legal or equitable owner?
/da-'i lii:. , .❑Yes ❑No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with`wtibm�-
If name on record is different than that of applicant,indicate below: t Is th property in question:Annually Assessed
eal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller — •
Address of mortgagee or contract seller(numb and street,city,state,and ZI code) .
Name of assignee or other owner or hol• ' age
O9 >V ' 4 0;;;;1 ,.0/ 40- 7.- •
Address of assignee(number and stye ci st• and ZYP 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 county on property for
in Indiana? Yes No❑ ❑ current year? III Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the per - ---- --�" -ie county
recorder's office(including day home equity fine of credit that is recorded in the cour, I / /Ll AS e��N�(f�/ /1 J�
. 'COUNTY AM1 l/� 7
Deduction approved in the amount of:
i)0 .—c597 i OL
20 , 20 20 20 Si nature,o ou Au or Cor //U(j
% 0,X)
J-).-4:-,4;&-ze..), .
I/We rtify under the penalty of perjury that the above+and foregoing information is true and correct and that the applicant is a resident of Indiana and
own /contract buyer of the aforementioned property on date application is filed.
Signaatur (owner's full
fful name Date(month,day,year)
Full resi nt address of scan (number ,city,state,an. .,ode) .
5— • Q107%, • -/11/XedX e.e'
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 r Date(month,day,year)
. Address of authorized person (number and street,city,state,and ZIP code)
The penalties forperiury can include imprisonment uo to two and a half years and a fine not to exceed$10.000.