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°'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS ovm ' ear
FOR DEDUCTION FROM ASSESSED VALUATION
saze F«m a3�os �RS i z-0»
S � presmbed by DepaNnent ai Loml Govemmeril Finance �' k 2'L 2009
Fde Mark
INSTRUCTIONS: �7l � ��
To be 6ied in person or by mad wdh the CourttyAuditor W the courrty where fhe propeAy is bcated.
Fding Dates: i) Real Properly: Dunng the 72 months before June 77 olthe year the deduc6on is to be elfective. Q��ypry en� �uTa, AUOITOR
2) Mo6ile Homes essessed imder IC 6-7.1-7: Behveen January 15 end March 2 of the year the deduGim �s f be 77gtbJ
See 2verse side /ar additional insWClions and qualifications.
(avner
restricfians qn reverse sde)
real pmperty as aa Inaim t. anenl y�r I M«tgage � cortlrza indewedness
aR�Y�+ //Y�/ a _
eracl share af iMe2st7
recortl is diflerent than lhal of applicant,
Name of rtangagee or conUaq
Address of mortgagee v contraG seller (number aM
a dher owner w hdCer d martgege
(num6er and straeC dty. Aate, aM
Does applicaM wm propeRy in any olhet
couNy in Indarel
❑Yes ❑ No
Deduction appmved in �ire amauM of:
n
SigreNre of Counry AudCnr
zo
a5 af Marrh 1.
IIf ownetl wiN Sortledle
r.
.o'i�Q�
sfate. and LP co0e)
�
couNrr nui
Rem�d rwmber
a
❑ No
spouse, ird'icate with whom.
Is Ne propaM1y in questim:
m.Real PrwerN ❑ Moble Hane
Dra�►•er nip, Q °on�
�� .••.. !es ❑ No
Y....
Card nip (a/3 %
� _ . ..........
`�Z '� l�g y 9� oo . ..
z° � z° — � 2° � —
c«,�a
�
I/ We certify under the penalty of perjury Ciat tlie above and foregoing infortnation is We antl cortect and thal the appGnnts was / were a resident oi
Indiana and ovmer of the afwementioned property on March 1, 2b _
Persan
s4eat,
IC
person (num6eranQSGeet. cdy. sfate, a�M
Date (month, daY• Yee�
Oa1e (month, day. yea�