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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDN e_ t 0 a. ,__ TownshipYear
FOR DEDUCTION FROM ASSESSED VALUATION ,� a State Form 43709(R14/1-20) •Prescribed by Department of Local Government Finance ° � 1 - ��
File Mark
INSTRUCTIONS: To be filed in person or by mail. 1.'\ FEB 2.2021
Form filed • :
Filing Date: Form must be completed and dated in the calendar year for whi e deduction is sought. County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the w ere h ro r
located on or before January 5 of the calendar year in which the property taxes > ❑ County Recorder
UNT AUDITOR
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side) N
a' $ — /a -IV- qo3-e49e. yid_ D 0, 7 :2o2-k 82
Assessed value of real pro erty 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 date of applica iory D 0 6 legal or equitable owner?
Yes No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: I Is the property in question:Annually Assessed
'eal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
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Address of mortgagee or contract seller(number and: l
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,am � � / 78
Does applicant own property in ny If yes,what county'? What Taxing District? Has this deduction a requested If yes,state amount of deduction
other county on property for
in Indiana? Ill Yes No current year? Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or ontr t 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 offi )that i the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 - 20 20 20 20 20
Signature of County Auditor County Date(mo h,day, ear) el 1
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I,We certify under the penalty of perjury that the a ve and foregoing information is true and correct and that the applicant a res' ent of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signat r (owner's full name) Date(month,day,year)
\11
Full resi ent address of a lican number-nd street,city,state,and ZIP cop)
t 13° F /5ts ` i � D(170
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.