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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
° �,N ),,
� State Form 43709(R14/1-20) �1�)�(i►� Q%��rryi� 7
a ✓ Prescribed by Department of Local
Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. Q-"County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is
located on or before January 5 of the calendar year in which the property taxes are first due and payable. ❑ County Recorder
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-/see restrictions on reverse side)
1-1b//4 — 41 o G0- oNkvrt
Taxing District Key number/legal description Record number Page number
./4cl'1—fcc j �6-17-/d -/bO -C�c:tj. qo - ram ( ) 65 7I
Assessed value o real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpai as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
C/.GLrk> tz ❑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: Is the erty 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
Drawer NO G I Fr T■��
Name of assignee or other owner or holder of mo IL
HAddress of assignee(number and street,city,sta. Card NO. ....V3-.r-!..a..t.... p( 1 (�-��D
Does applicant own property in any" If yes,whs t p requeste9'�r 'Ig yl, 20e2 unt of d duction
other county L^�T,"�� Yes ❑No
in Indiana? ❑Yes o
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contrac set. the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)that i v Fi ved TOR
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of Co my Auditor County Date(month,day,year)
ied
I/We certify 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
owner/co tract buyer of the aforementioned property on date application is filed.
( YuII nameDate(month,d year) ry'
r ident/ad�ss of applicant(number
t,city,st ,and ZIP code) �J �`
(260 w 550 S 401 uev ,J'Ake -A!i '-!76Cow
Person authorized by duly executed Power o 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.