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,4.--f ,, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
;� FOR DEDUCTION FROM ASSESSED VALUATION G hson ��tlnc�ton
4ttiy) State Form 43709(R14/1-20)
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 County Recorder
located on or before January 5 of the calendar year in which the property taxes are first due and payable.
El See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Stephen ,71- &-/c /1 e 1-1c—f15
Taxing District Key number/legal description R orr®umbe PAc_i ci er `
Pc�,�cf✓tor a (o -1, --07-/oa-cbo. Y5 g K I -`{J1Tl\J
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness Lind asibf t applicant
equitable the
owner?
Is sole
assessment date,current year assessment date,current year date of application legalq
a
Q O G7G� Lies ❑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 perty in question:Annually Assessed
eat Property ElAnnually Assessed
Mobile■T Home(IC 6-1.1-7)
Name of mortgagee or contract seller
T J�L
L.1 f CV FI
Address of mortgagee or contract seller(number e D;< a w f✓I NO..,
Name of assignee or other owner or holder of moi AUG 2 6 2022
Card NO. a-7c)c) 1a Address of assignee(number and street,city,star
Q1L.cJ O Ts, a►►DITOR
vvnat iazin _ uction bddi5 S �f yes,state amount of deduction
Does applicant own property in any If yes,what county? 9"""'�`` on property for
other county ❑ rY I current year? S ❑No
in Indiana? Yes LJ No
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 Date(month,day,year)
Signature of County Auditor //'' / o—(9 /
— !/ IA, ,,O� OL
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/contract buyer of the aforementioned property on date application is filed.
Date(month,day,year)
Signaturen (owner's full name),�/
u-1,1,-- CI f /.2�/2 2
Full resident address of applicant(number arid street,city,state,and ZIP code)
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Si-- r l c e fo Z,I✓ `-( 7 7 2
/ao 6- �al1u� �- t� r
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 510,000.