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� i "'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
� FOR DEDUCTION FROM ASSESSED VALUATION Cou s: p Year
�, N. -J SUte Fam 43709 (R6 / 5-OG) �
Presaibed by Depertment of Laal Gwemment Finance
JUN 0 S 20 •
INSTRUCTIONS: File Mark
To be filed in person o� by mail with the County Auditor of the county where the propeRy is located. ��.� ���
Filing Dates: 1) Real P�opeity: During the 12 months before �une I i o! the year the deduction is to be etfee(iv�
. 2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of fhe y�e���6rt iStaBeeifective.
See reverse side fo� additional instructions and qualifications. �
Taxing
Assessed value of real property as
March i, curzent year
If no, what is his / her exad
see re��'�ons on reverse side)
!
f ey number / Iegal description
' J'D i
if Mortgage / Contrad indebfedness unpaid as
March 1, current year
If name on record is difierent ihan fh,at of applicanl, indicate below:
C
I
of mortgagee or contrad seller
�00 ^� _
3 8'�S�
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�<!°'"� „t`°'o �
Signature
Gty.
code)
Record number
Page number
is me appucanc me soie iegai or
owne(? ❑ Yes ❑ No
owned with someone olher than spouse, indicate with whom.
What Taxing Distrid?
COUNTY AUDITOR
20
County Auditor
�
❑ Real
O Mobile Hm�e (IC Cr1.
Has this dedudion been requested on
property for current year? � Yes ❑ No
20
20
� We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
resident of Indiana and owner of lhe aforementioned property on March 1, 20
� Signature (ow fs (ull name) Person authorized by duly executed Power of Attomey
� P� �� ,nl� o� by ic s-,.i-iz-.o�
�s FuII resid�nt address of �applicant Q��\PNC� ��'r�+- �
il� `.�'t�..-i���;� � c-t�r���
of authorized person
: