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.`,-`-'"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTE S— ' CountyTownship Year
� � FOR DEDUCTION FROM ASSESSED VALUATION �2�
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"� I' �+ State Form 43709(R14/1-20) l;�, *,
**' r i'' Prescribed by Department of Local Government Finance
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File Mark
INSTRUCTIONS: To be filed in person or by mail. JAN 2 L+ 20�,
V Form filedwith:
Filing Date: Form must be completed and dated in the calendar year for which the ction is sought. Xl County Auditor
Must be filed or postmarked with the County Auditor or County Record yilf ere.t e property is //��!
located on or before January 5 of the calendar year in which the props �e u, ;,r •,:yable. ❑ County Recorder
See reverse side additional instructions and qualifications. NTY A iDiTOR
Applica t(o r contract buyer-0 trictions on r: rse side)
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Taxing .is' t Key nu legal description 0 Record number Page number
.....0 0 , .(--1,41 _://c/-17
Assess::value of I property of Mortgage/Con ract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appli ant the sole
asses• ent date, rrent year assessment date,current year date of application legal ore uitable owner?
gaft) Yes ❑No
If no,what is his/her exact share of interest? If owned with someone other th n(pouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is th roperty in qt
Real Property --.9C
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Name of mortgagee or contract seller
/47,
Address of mortgagee or contract seller(number and street,city,state,an ZIP code) O
Name of assignee or other own oom rtg :• Q / / / // I ry
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Address of assignee(number and st el sta e,and ZIP code)
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Does applicant own property in any If yes,what county? What Taxing District? Has this ded -4`,een requested If yes ni
other county (�
in Indiana? ❑Yes ❑No currrentyear? t_,Yes ❑No `�C,
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or'ontraa indebtedness thl
recorder's office(including any home equity line of credit that is recorded in the county recorder's offic- that is the basis for the il
COUNTY AUDITORS
Deduction approved in the amount of:
5t.'s it
20 20 20 20 20 20 s
ignat of C utly A itor i2County \ \^ Date(month,day,year)
I/ certify under the penalty of perjury that the above andforegoing information is tl and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
j....... n ture(owneeN name) — Date(month,day,year)
Fullepf adds of app cant(numb a tr f, ity, $:,and.IPJ� '� �--� % a \
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 CC�� 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.