Mortgage_Hooker (3) d,so-r- STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
1 FOR DEDUCTION FROM ASSESSED VALUATION
n^ }old
�- State Form 43709(R14/1-20) V 1 b,>�� .a
�� .�', Prescribed by Department of Local Government Finance TW/ISP
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 El County Recorder
located on or before January 5 of the calendar year in which the property taxes are first due and payable.
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
l3rettda N 00 Kew
Taxing District Key number/legal description Record number Pacye � i
f.,_.- at -fic>� I aCo-i8-'3- you-Occ- W/S - aa6' /�/I/L`"'I6 S
•
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of dMaoprtgage/Contract indebtedness unpaid as of Is thealor egapplluttablecant the
sole
assessment date,current year assessment date,current year J��/ LI O�
owner?
`14YA 171-YeSr ❑No
If no,what is his/her exact share of interest? I If owned with someone other than spouse,indicate with whom
I
If name on record is different than that of applicant,indicate below: j .. fPPertY Is the p in question:Annually Assessed eal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
e-T � o
Address of mortgagee or contract seller(number and street,city,state,anc Drawer NO..... ti
_ W N ¢
�S F�1 >
Name of assignee or other owner or holder of mortgage l ~
Card NO. o
Address of assignee(number and street,city,state,and ZIP code) �i Q U
Z
O
Does applicant own property in an If yes,what county? What Taxing District? I Has this deduction been re uesrea je..state amou uction m
other county Il on property for e5 ❑No 111
in Indiana? ❑Yes NO current year? C..
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract 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 office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 I 20 I 20 20 20 20 20
Signature of County Auditor )I.b 'cz_
Date(month,day, ear)
iJi 54 Ai A A _ WO? ?oaI/We certify under the penalty of perjury that thbve and foregoing informs true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned pr perty on date application is filed.
Date(month,day,year)
Signature(owner's full name) D h,07 s/Z -
J�-z ,---
Full resident address of applicant tuber an street,city,state,and ZIP code)
105E U/e•, 6y,-+ re%t rp/ L/7(,I/
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)
1
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.