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STATEMEN cBTEDNESS County Township Year
z FOR DEDU Drawer NO,.. 6c/7[�/ b�^ }. Y3ra�ak
State Form 43709 f.{� v. Z Z
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File Mark .
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INSTRUCTIONS: To be file c! Form filed with:
Filing Date: Form must be comp/cr.,....._ deduction is sought. ergunty Auditor
Must be filed or postmarked with the County/4uu,..... _.
Applicant(owne r contract buyer-see restrictionw reverse side)
Taxing District Key number legal d l9 e ri n Record numb P ge number
_, .'(Xa,t`c�n. ,z,D f? - - (Q l - 000. ISO-0 a LP. 7--,C) 2 q 5-.
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 applicatio legal or equitab a owner?
S ! O es ❑No
If no,what is his/her exact share of interest? If owned with someone other tt1tan spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
I Property ❑Annually Assessed
- lr� Mobile Home(IC 6-1.1-7)
N me of mortgagee or contract seller
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Address of mortgagee or contract sell r number and st city,state,and ZIP code) OFC
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Name of assignee or other owner or holder of mortgage z,022
Dyes
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Address of assignee(number and street,city,state,and ZIP code) a Co c „ ,
A
Does applicant own property in any If yes,what county? What Taxing District? Has this deductio en requestecci tate amount of deduction
nty on property for Yes ❑No R
inoth Inerdianacou? ❑Yes El No _ current year?
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or cont 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 the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor County Date(month,day,year)
I/We certify under the penalty of perjury that the above nd forego ' formation 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)
Si t (owner's full name) �,p��—"�.Z ,
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ull repssiiddennt''Iaddreess of applicant(number and street,city,st ,and Z/P�ode) , q . ��-7 p,
erna L cd b .P� '�� 7 N Datle(month,day,year) i
Person authorized by duly executed Power of Attorney r 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.
RECEIPT FOR FILING STATEMENT OF M T CONTRACT INDEBTEDNESS
Name of applicant mortgagee or contract seller
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Date filed(month,day,year) mount of ne vt." ) L.axing District
Key number/legal description(-]l ` (� - = ,pr -(OC
Z` Q • `�‘ _ t� "- Don 1/ p•O Date(month,day,year)
Signature of County Auditor/County Record Cou �y
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