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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION .-at-� n�
State Form 43709(R14/1-20) G 1(O Soh d
^. . .� Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: To be filed in person or by mail.
the county where the property is ❑�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)
� � li- e
r stC-
CANOLC`CI+` ede PAO COCK Record number Page numberQ
Taxing District Key number/legal description c,.96.7� � 1 ��
?&—k-CIF (X,-• /l- /5-)0O - cx 1 Oon- off� 1
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is Is the applicant the
e sole
assessment date,current year assessment date,current year d to of application g
er?
17, qoo ❑ ❑No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
Is the roperty in question:Annually Assessed
If name on record is different than that of applicant,indicate below: t, teal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller p.. FILE D
Free-dwn o tv. Drawer T O....R.C�22'..
Address of mortgagee or contract sellermber and
Name of assignee or other owner or holder of mortgag Card NO. .....t.9.q.5:-...• J U N 2 2 2022
Address of assignee(number and street,city,state,an /��)ZeG/.,,e a ./ �//
BS
Does applicant own property inanti If yes,what county? What Taxing District? Has this deduction been reqGutes eON 9 e 9a/t11 i%abtkduction
other county �-„C on currentprn yearty for L6[ L e " No
in Indiana? ❑Yes C���o year? s ❑
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
20 20 20 20 20 20
County / I Date(month,day,year)
Signature County )ditor`J. _ ?/ 4 I b 59 n C./.7...)/c
I/We certify under the 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/contract buyer of the afore ntioned property n date application is filed.
t Date(month,day,year)
Signature(q�ofjers f a j e)
(rt/t n�a(a/�Al I (///���j�tg t9 2 2- 0 7 7
Full reside es o applicant number as street 2Ry,sta ee.,J and
CZIP code ! 7 O
5�9 5 I; o-r✓` `^ ' ‘ V Date(month,day,year)
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7
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.