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.• "�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS T h' Year
- FOR DEDUCTION FROM ASSESSED VALUATION
�-• sraie F«m as�os �ae i 2-0i� �,
S � Presrnbed by DepaNnent W Lacal Govemment Finance
.��� aFbe�}�•
INSTRUCTIONS:
To be filed in person or by mad wifh the CountyAuditor o7lhe county whera the property is located. �...,
Fdmg Dafes: 1) Real Proper(y: Dunng the 12 months be(ore June 11 0/ the year fhe deduction is fo be eRecGve. �a� ��,
2) Mo6Re Homes assessed under IC 6-1.7-7: Behveen January 15 and March 2 0l the year the deduction is to b�,¢Ilectiva�'
See reverse sde for additional insbuctions and qualiTicafions. � �Q81L47'1P �Qg�
Applicanl (ownu ar wnLa er ee iesLicfions on raverse "de)
� '
isUid Keynumber/legaldesaiption �/
�- Y =
Asessed r�ue of real P�P�Y az d Mard� 7. amenl Y�r Mortgage ContraG indebl�
airtent Ye � J
Q
{�'-�� what is his I her ezaG share of imeresl?
If reme m recwd is dit(erent than Ihal of applicant i�diple below:
Name of rtartgagee or contraa seller ���
AdAress of mortgagee w mnUacl seller (number and sf�eel. dty. slate, aIM ZIP cotle)
unpaid as of March 1, I Is �he appfirant ihe sde legal or equitable wrt�e(
❑ Yes ❑ No
med wi�h someme o�her ihan spouse. indcate wiUi whom.
Nama of usignee w alha owner or hdder of matgage
Atldress ol asvgnee (n�mNei aiM sGee; city, sfale. and ZIP mde) . .
Oces applicaN own propertY in arry dhrs �f,]( f7 �..GiJT� •�T"`�+Y� ��--
caunry in IndareT V (�y��(�
❑Yes ❑No �C1��'el' ���..�.'.^.:T..�.:.: :'�
Deduction appmved in ihe
Q�ti��
Card \`O. ....�y8.........
� $'1,Sa0. °r�
Caunry
Is U�e poperty in questim:
❑ Real Property ❑ Mobile Home (IC 61.
Has Ihis dedudion been requasietl on property
for airrenl yeaR
❑ Yes ❑ No
2� _ � 2�
day, yea�
I/ We certify under ihe penalty oi perjury ihat the above and foregoing infom�ation is We and corred and that the applipnts was / were a residenl oF
Indiana and owner of ihe afwemenUOned property on March 1, 20
,me�.o ���.,r� fidl �uM1 A Date (mmN, daY. Y�d
Adtlress of autFwrized persrni
ind sGe&�y1y. slate. and ZIP ootle)
5 `
of Attaney w by IC G1.1-12-.07
'sLee( dty, slale. aM LP oode)
Dale (mm(h, tlay. yea�