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�.._ ..,,, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
100441.. FOR DEDUCTION FROM ASSESSED VALUATION f/�/�
State Form 43709(R14/1-20) ((J� S� 0 2`
Alto.�, Prescribed by Department of Local Government Finance J 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.
Appl' nt(o er r contrr tf buyer-see rip tions on reverse sidgij4
Taxing ' t • Ke number/legal description Record number Page number
el -/O-�-,700- GYJ/. /G6- O C2 �D-? .?
Assess value of real property as of Mortgage/contract indebtedness unpaid as of Mortgage/Contract inde dness unpaid as of Is the applica t the sole
asses ent date,current year assessment date,current year date of application legal or equitable owner?
C ❑Yes ❑No
If o,what is his/her exact share of interest? If owned with someone other t an spouse,
use,indicate with whom
If name on record is different than that of applicant,indicate below: Is t roperty in question: ri-a Assessed
eal Property a A e sled
Name of mortgagee on ct seller - 7
Address of mortgagee or contract seller(nu ber and street,city,state. n ZIP code) I Q
Name of or other. rier hol er f gage C,�J� 204,
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/ � `�� to o?-/� / �� "°O"ti
Addres as n/- number and street.city,state,and ZIP code) /,f(f
o/` p,
Does applicant own property in any If yes,what county? What Taxing District? oHas n propertyisdeductio b en requested If yes,state amount of deduction
other county ❑Yes ❑No
in Indiana? current year? Yes 0 No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or c t ct 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 I the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of: •
r��l C /J r' /�
20 20 20 20 20_ C&-f�, z EL1/_Z5 IC--.
Sign ure of Co ny A 'tor ,4w.... 7Country /YA 71--7-S
I/We ertify under the penalty o perjury that the above and foregoing informati 's true and c
owner/contract buyer of the aforementioned property on date application is filed. C/�
Sig t re owner's full name) vl(J`�,`�(/ a7 /]1`'
3 tirs(zi2k,4
Full res dent address of applica'it(number and street,city,slate,and ZIP code)
C �• - AV. �` � Date(month,day,year)
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12 .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.