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n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__ , FOR DEDUCTION FROM ASSESSED VALUATION ' /
� Stafa Fortn d3709 (R11 / fiO9) (/
�' ,.,, Presmbed Cy Departrtie�rt w �ad Goremme�k Fu�ence
INSTRUCTIONS: wa�
b be filed in person w by ma�7 with fhe CountyAud�rtor or Counry Recortier ot the counry where the property is located. � L u� Q
Fi(rng Dates: 7) Real Proparty: Must file during tha year lor which the deduction is sought O Counry Auditor
2) Mobde / ManNactuled Hortres not assessed as Real Property Must file dunng the hvelve (12) monMs
6e/wa March 37 0( each year the deduc6'on is myht ❑ Co nry Remdu
See 2verse side 7ar adtlitional instn�uions a� qualificaGons.
Ta Distr'uY U Key rwmber I
d���,�,Y�� " 3
i. almlit ytlt M
H m, what b ttis / her evrt share ot Ntuest?
tt rarte m femd'o 6fterrs� Nan tlial W app&an4 h
Name at rt�orto�ee «mnvxt se4er
�oo -000. �a8 oa
Contract uNehOeEness unpaid as d MMgage / CanO
AEdress d mor¢jagee or mntract seAer (nuMri and sveeL �: s��.
Name of assi�ee or olhv awner m haldm d mortge
nearess m assKy,m ��umee. �e �c ray. smre. :
Does aPp6fant wn popeM1y in any oNer
caunryminEena? ❑ Yes
❑ No
Detluc�on aDWoved'e� ihe amount oF:
20 _ 20 _
Sianahae of Co�mN Autlttor
swr�eone
1-f�i�-sou, ����� �
�D/D - %D� %
20 I 20 I 20
Retofd n mbG Pag twm
�
rtetlness unpaid as of Is tlre app&ant Cx sde
�G9L� Of CQUIt261B bwI1G(1
❑ Yes ❑ No
spouse. 4Wimte wit� v.Tnm
Is IM PbPeRY in 0uestim: MnuaOy Assessed
❑ Reai RoPertY ❑ !4rmuaDY.0.s�ed . . _
Has mis
tor uufe
p
Ym m p'apeny
Yes ❑ No
�Y Y��
�
� I I We certify under Ne penalry of perjury Mat the a6ove aM foregoing infortnaUon is true and cortect arM Mat the applirant is a resideM of IMiana and
owner I wntrac[ buyer ofSye-�(arementioned C�GertY on date aPWication is filed.
\ � � reme / / / / Date (rtmtli. deY. Yee�)
aWo�eO Dy dWy eze�vleE
Gerson (numDe� aM sbaeG �Y. stufe. aM LP mde) .
oa�e (�,�,nn. aa�: n