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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
�; FOR DEDUCTION FROM ASSES � n„f State Form 43709(R14/1-20) y.�f- ,L) �//�\, ..��'� O T `UV��
Prescribed by Department of Local Governmen a
File Mark
INSTRUCTIONS: To be Tiled in person or by mail. APR 2 O 2022 F 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 Re order of the county where the property is ❑ County Recorder
located on or before January 5 of the calen 4 h thyf �7jy1&ces are first due
Apa.n�t.( ,er or cote , yer- ee re trictns reverse e)
Taxing Key number/ egaldescription Record number Pa
imber
�- . 2-6 _V2 0-6-?-01--0 00• S�2 d 2q-_ ( 1 Ql 2 .
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is legahe l a quentlthe owner?
sle
assessment date,current year assessment date,current year date of♦pq lirrat O D' 9
11 � U es ❑No
If no,what is his/her exact share of interest? If owned with soo o e othe—han spouse,indicate with whom
i
If name on record is different than that of applicant,indicate below: property in question:Annually Assessed
RReal
Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mod orageet_► nt L '(
contra N.
econtract \_Q`/1
Address of of gee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage �t tI'' /� b �(�A'/�
Address of assignee(number and street,city,state,. I� A 1 El.��l ` vO�///J
Does applicant own property in any If yes,what cot I l on - I ) requested If yes,state amount of deduction
in her
Indiana?county ❑Yes El No VT• ElNo
ot
A person is not entitled to this deduction unless ti ndebtedness that is recorded in the county
recorder's office(including any home equity line c ..—,,ice)thatlis the basis for the deduction.
.. 'uNTYAUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor County ate d xearr).�I/We certify under the penalty of perjury that the above and foregoing information is true nd correct and that the applicaInebrol,
t is a re 'dent of Indiana and
owner/contract buyer of the ementioned property on date application is filed.
l / Dategnopth,day. r)
1 / Signatu (gtWner's I namAg7 1 '/',�$16 (`'l f \lf��
\/` Full resident address of applicant number and street,city state, d ZIP ode)
63 F lsxke_ ` ,r1wo06 ? for- 9'n-�l 1 -
Person authorized by duly executed Power ofAttorney 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.