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_., STATEMENT OF MORTGAGE OR CONTRACT INDEBTEFNE� rI) Township Year
�,�"� 4f FOR DEDUCTION FROM ASSESSED VALUATION
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State Form 43709(R14/1-20) O C'T � ���
Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: To be filed in person or by mail. /�e ./_ Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which the dedriardrf �YN.TyJ/A�UUD r� County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where the proper 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.
•
Ap lica niter or c tr t buye see f�stn its on rev rpe side)
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in istrict • Key number/legal descrip on Record number Pa a umber
(� olio -/, —.�3= O- . f2.,-- 6�� CV
Assessed value I pr erty as of Mortgage/Co tract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment d to year assessment date,current year date of applic ton legal or equitable owner?
❑Yes ❑No
If no,what is his/her exact share of interest? f owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of-x contract seller
Address ot�ortgagee or contract se er(number an s e)t,city,state,and ZIP code)
Name of assignee or other owner or holder of m - /�
• 'de)
No.. a0Ar L'......... 9 yes,C1 What Taxing District? Has this deduction been requested If state amount of deduction
- - on property for
current year? ❑Yes ❑No
al/ .••.•....•• n has a balance on the person's mortgage or contract indebtedness that is recorded in the county
Car d ••• a#Q that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
1 _.....uiir Or:
20 20 20 20 20 20 20
Signat of oL4ry uditor/J a CountyD 30'. ate(mon h,da ,Yea_r) Z
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1/ rr//e certify under the penalty of perjury that the above and foregoing information is true nd correct and that the applicant i a re ident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signature wner's full n Date(month,day,year)
A Fu I resident address of applicant( umber and street,ci y,state,and ZIP code)
9�• L/�0 S' � W- 1T1 '4-7 6 t 0
raerson authorized by duly executed Power of Attorney or by IC 6-1.1-'12-0.7 n 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 510,000.