Mortgage_Smith (17) —•, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
a _ % FOR DEDUCTION FROM ASSESSED VALUATION O� 02� �022
State Form 43709(R14/1-20) J
�� Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: To be filed in person or by mail. 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
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.
Applica (owner or contraccuyer-seer estrictions on reverse side) /�
Pa a number
t lS�n- 2G -2-f—/i- z�v�,z-173/- �a,74 2°2-1 Eiz�
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equita owner?
�/rieti es ONo
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 p y in question:Annually Assessed
eal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mort agee or contract seller ``
f" / /./_ Y(�nc� � T S - A.
Addressof mortgagee or contract seller(number and street,city,state,and ZIP code)
PN��aQ\ J
Name of assignee or other owner or holder of mortgage 1 p7,
Address of assignee(number and street,city,state,and ZIP code) IC ET-FC__ v\.
Does applicant own property in any es,what county? What Taxing Distr ) 0 C' coo, 0 0 a amount of deduction
other county
❑Yes o
in Indiana? C 2 1 - 2 8 8 2-
A person is not entitled to this deduction unless the person has a balance on.••��,...„�•,.,..y..y..-• __.. 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
ce
Signal r of Cou AAud� of / /--j�/// n ^ Count — Date(month, a_y,yalli -0
I/We certify under the penalty of perjury that the above and forego) information is true and correct and that the applicant is a resid> t i f I dianadaud
owner/contract buyer of the aforementioned property on date a li tion is filed. •-i >-
igrrtat re(owner's f tl name) lsyl,k.,..td--\ Date(month,day,y ar) , Z
1 J O
Full resident address of applicant(number and street,city,state,and Z/ code)
1f/o 7 T� U Job- Kor , 4� �-- 76 3� �
Person authorized by duly exe d Power of Attorney orb 1 6-1.1-12-0.7 Date(month,day,ye r)
ciD
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.