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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
_ : FOR DEDUCTION FROM ASSESSED VALUATION
• StataFwmd3709IR11/609)
��N. � Presaibed Oy DePaMreM of Lawl Govemment Frunce
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To be filed in person o� by mail wifh the CounryAuditor or Counry Reco�der o! the counry where [he property is located. IYI HR V 1� 2 � � 1
Filirg Dates: i) Real Pmperty: Must �le durirg the year for whirh the deduction is sought County Aud'ROr
2) Mo6de /ManulaCured hbmes not assessed as Real Property: Must file dunng the hveNe (12J monNs C
before March 31 oleach year the Ceduction is saght. emrder
SeereversesideloraddifionalinstructbnsaMqualifications. ,�,,,�,,.,,,,,,,.,r� �,,,,,r„o
Ta ' Dis 'ct Key nmlkr I legal desaiption �
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rahie d mal proputy as ol Mor(p�9 e/ Conlraa IMebteEness unpaM az ot
. a�renl ym Mart3� 7, arrerrt yenr
y
K 110. W�1'd� 6 �16 � i12f fX2G 5�12I8 O� IlIiClCSi� �i OMT1!
If rwrre m n.md'a �rterrnt lhan that of aPpOpnt, trMirate Eebvr.
��oontrau seller
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Pddr¢ss d rtnrtqagee n cantraa seDer (nur� and stree4 �1: sb.e, aM LP code)
Name o1 assignea w ather owner w haltler of morigage
AAdress of a55ignce
apaioN ow,� vroaem � aoy omer
y m InE'ana? �
❑ Yes
ction appfovad m �he amount af:
20 _ 20 _
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nVact cWehte0nes5 �mpaid as of Is Ne
Sion legal
No
�tim: Mn�aAy hLSessse0
� /Vttlually0.55essed
Alobile Home (IC 67.
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Counry
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I I We cerafy under the penalry of perjury that Ne above and foregoing intortnatim is we and cortect arW that the appfxant is a resident of IrWiana and
axner I wntraa buyer of the aforementioned property on date application is filed.
7 re(owners (uH qame) ..fl n �(�. daY.1'��
Person auNOrized Cy
ol aparant (num6ararM stree; cdy,
m
person (num6er arnd sbaet, rity, stafe, and ZIP cade)
Date (monN, dal: Y��