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^'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship Year
,_,. ; FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 93709 (R11 / 6-09)
S,,,, � Prescibe0 by �ePaN+�m of Lo�l GovemmeM Firence � JL �J
File Mark
INSTRUCTIONS:
To be filed in person or by mail wifh the CountyAuditor or Counry Recorder o� the counry where tl� g��pP�rq� is(p�y ed. F� �� ��'
Filirg Dates: 1) Real Pmperty Must file dun�g fhe }rear /or which the deduction is sought J U IV 1 3 L U I 1 ��unry Auditor
2) Mobde / Manufactu2d Hortres rat assessed as Real Proper7y: Must file dunny the tweHe (72) months
befae March 31 0/ each year the deducfion is sought C� ry�,--� " ❑ Cuunty Recorder
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See reverse side (or additional instnict'uns and qualifications. i V C
Tarirg D' ' Key rcan legal AesaipGm rwmbrl Page
�- a -�m -�.c� �s v I �`a,s
Asessed rWUe d mal popeny of AW�ge / Contraci intlebte7rress unpaiE as U Mw�qage / ConVact'u�Cebtedness un7� a d is Ne aGWimnt the sde
I1laich 1. aarmt year Ma�th 1, a� �y date o/ eppGfation legal w equitade oxvrel.+
v � ❑ Yes ❑ No
It no, whal is his / her ezarl share of interesl? If ownetl wiM someone other ihan spouse, iMipte w%h whom
It name on 2mnC is dAFrlent Nan Nat af apptirant. IMi�ate bebw I5 �h¢ prop¢rty in pue50on: Mmially PssesSeA
.-. n ..� ,. ❑ Reai amaerty ❑ enoa�� �.�-n
Name m rtartgagre ar mnvaa se�ler �/ �//
�`C
AEEress W mortgagce v mntracf seAer (nun6eiand shee; city, s
Name at assignee a oNC ovmer rn holder of mortgage
AdGress of assigiree (ru+mber ad svee4 a1y. slate, antl ZIP cade)
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I�-+..� +�.. ��b. . .If vnc. wh:
1� wirl AN,���
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sg�an,rewco�,ry ��, r
,
I I We certify under the penalry
owner / contracl buyer of the a
SM1�M1�re/o �slu0nar�91
rem,m awnrrsea oy eWr �erLted
ldC2ss of authar¢ed person (num
(YIUfIM
jury that tljp above and fc
!ntioned properry on date
W�al Tari�g Distna?
AUDROR
Ihis deduGion bean requested an PropertY
urtent yeaR r-i . _ r� .
� � �_ �
��ry �� �,�,. �Y �
�C�--13- li
in infortna�m is We and mrtect and that the applipn[ is a resident of IrMiana antl
" tlon is filed.
Leef, tiry, sfate, antl Z1P cotle)
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n,�rey o. nr ic s,.,-, z-0.�
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