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"'� IiSTATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship Year
� FOR DEDUCTION FROM ASSESSED VALUATION '
sr�aw�,,,a3�oa�awuos> � DULYENT REDFORTAXA ION
�' ,.,� f Presoibed by Departmen� o(Lacal Govemment Fnance � .
� File Mark
INSTRUCnONS: � _ day of -
To 6e filed in person or 6y mail with fhe CounryAUditor or Counry Recorder of th\ unty where the property " ted. F� �� ��
Filing Dates: 1) Real Pioperty: Must file durrng the }rear (or which the deducfion is soughL ��,Co ����y�
2) Mobde /Manu/actured Homes rrot assessed as Real Property Must file dunng the lweNe (7 s '�yj.��,`���Y
before Ma/ch 37 0/ eacA year the deduclion is sought. �� j ir
See reverse side (a addi[iunal instr�ctions arrd qualifications.
M (owre� or convact Duyr�' see restn�w�s an revarse sldel'
Parcel �
uypp Distriti Key �umiber / legal desaiption Recoid numCer Page number
�� 'I-(o' lY'-D%' 3 00- O00• IIoI -OO �o a-OOQ (o �(�
sessed raNe dreal property as d Mor�qage / Cantraa intle6tetlness unpaid a of Mwigaqe I Con�act'uWebteEness unpaid as of Is the eppfimnt the sde
ardi 1, qarent ym Mamh 7. arre�rt yrar ' date o( eppGcation kgal w epurtade o�w11
O ❑ Yes ❑ No
m, what is his I her e�c[ share of interesi? It wmed wiM mreane otlur Nan s{puse, irid'xate weh whom
name m 2mrtl is dAferent ihan Nat o1 appa.ant, indinte bebw: Is ihe property in Question: MnuaM Pssesse0
❑ Real RoPenY ❑ �!�Y � . , _,
Nart�e W rtnrt�a9� w
Address af rtnr¢)a9ee or contraG se�er (number end streeL �; sfate. arN ZIP c'
Name o1 assiy�ee ar othel owner w t+dEer d mptgage \
Mdress of assiry�ee (num6ar end sheeG �Y, sfate, erd ZIP cotle)
Dces eppfimnt ovm yoperty in any other
mwuy m Ind'ana? ❑ Yes
DeducCa� approved in Ihe amount af.
20 _ 20 _
Sigruture d Camb nwitor _ �
If yes. what
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c��.� �o . ................ ,����,o�
� L��u`1' `i`" � Yes ❑ No
cou... � ,.uortoR
20 20 20
Caunry
�_
Dale (monfh. daY Y��)
Ps;
I I We certlfy u�er Me penalty of per¢iry that Me above arxf foregoing infortnation is true aIW wrreG arM that Ne applicant is a resident oF Indiana arM
amer I contract buyer of the aforemerrtioned property on da[e application is filed.
��� re(owners M1N nartre) Date (monM. daY. Y��
:�m'��-� � � /-/s /c�
1 revCent addmss of appfran[ (numDer and 5Lee4 mY• ��e, and ZIP mtle)
� E_ G�-iE'/�,��G � �y 1.✓ <1��� �
e=ewcea aower nramn,er a M�c G�.�-t2-0.7
Pddr�ss of auNU'veC person (number aM snee; riry, slafe.
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