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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__ : FOR DEDUCTION FROM ASSESSED VALUATION
- � • 5fate Farm 43,09 (R„ , 6-09� F I L E
�,�,� � Presai6ed by DepartmeM a( Lnral Govemment Firerce
File Mark
wsrnucnoNS:
To 6e filed in person or by mail wifh the CounryAUditor or Counry Recorder o/ the cou�{�h�e th�erty is located. F� �� ��
FiPrrg Dates: i) Real Pmperty Must file durirg the year lor which fha deduction is soughG �nry Auditor
2) Mobile /Manufactured Homes rat assessed as Real Pmperty Must�e,�yPeS�� " V(12J months
befole March 31 of each yoar Ne deduction is sought. ❑ Counry Recorder •
See reverse side rtan 1 instiucLOns en qual�fication .
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Key llegaldetaiption
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MMqage / Contraa
� 7, qxre1� yrar Marrh 1, artent,�q
M m. what Is tus I her ear� share of intsestt
It name on remrd a Qdferent Nan Ihat af app[
Name W morcBa9ce or mntrar� seuer
Add2ss d mar[9a9ee a cmtraci s�er (nwMer and �
Name a( assignee w aNer owner w halder of mortgaga
Atltlress o1 assicg�ee (num0erand sf+ee; rdy, state, antl
Does aPd�� � P�VenY i^ any oNer
muNy �n Intl¢fla? I"I ._ r'1 ..
zo
I I We
tlie amount oF
20
�00-?f' -oo
i as W Mortgage / ConvaH b�eebteMess
date ot appGtation
tt a+med wiM snmeorie athu than s7w+u. u
COUNTY
zo � so_
•'J
number
7 �v
Yes LI No
Is tl�e properry in QuesEOn: Mm�aOy Assessed
� Real PfopErty � Anf1U311yAssC55Cd
M1bble Home QC 6
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raArre oav�as
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zo I zo I 20
Counry oam (rtb+nn. aaY. I
� O�' L
penalry of ry that the above d foregoing infwmation is true and cortec[ arM that the appiicant is a resident of IrWiana ard
ot the afweme � ed pmperty on ate application is filed.
� Date montli. daY Y��
mnl (n r and sfree4 �: s+ate. antl LP
�% S"� � Oal�/a, C',� Y 660
Person autho�¢ed Ey dWy ezecutetl Power otAitort�ey or Ey IC 6t.7-t 2-0.7 Date ( O�O
Address of euthomed persan (numbcraM sbeet �y, sbte. antl ZIP code) '