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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEB�D�E� n Township Year
FOR DEDUCTION FROM ASSESSED VALUATION ���
Stata Farm 43709 (R77 / 609)
`,.,. � ��a�������,��F� JAN 2 5
File Mark
INSTRUCTIONS: C �
To be filed in person w by mail wifh fhe CountyAuditor or Counry Recwde� o/ the counry where the prope ted. F� �� ��
Fiting Da[es: 7) Real Property: Must file dunrg Me year fir which Ne deduction is so �h•L_ � Counry Auditnr
2J Mobde / Manufadu2d Homes rrof assessed as Real Property Musf fil�8tl$(�6hE��(p2A�
betore Ma2h 37 of each year the deduct;on is sayht R ❑ Counry Recorder
See reverse side for�d�ilional instructiwis and 9�lifications.
Ass¢sed ralue U �
MaRh 1, am�v Ymr
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n 110. M�18� 6 �YS � i121
lil12R1B Ofl lCWIO R �
�Y , .�J �/W -• � � ""^ / V m v ( P�e �/ �
qaperty es of MMpagB / Contrati indnbtedness unpaid as of MMgepe I CantreU uWebteEne55 unpaid as of Is the eppl'im�t the sok
Mart�h 1 artent yeer da /�/'\ legal a epuilade o�1
� OOVLJ ❑ Yes ❑ No
eYatl sh2lB O(NiPiCSt? HOwnBd with SOm¢Of�e N2fI5�d158.I�MIL21e Wlih whom
Name o( mort9a9ee m m�trau seAer
Addr� of rtnrtqa9ee or rnntraa seDer (nunOar end s0
Name al assi�ee m othu owner or hdder d rtartgage
ACaress ot astignee (ru
Dces appiksnt m�n
county m InCiana?
Deduction approvad i
�_
5+9wWre ty
I / We certrfy unde
owner I mntracl b
naNre (O h MI
I
Fu0 �ent W
r�: sate, aM ZIP code)
aMsi�-• __ '
a�� ..
D�'il\VCC `0•••.••.•••.••••• WhatTa�dr
�-}�� 1 � .....
C,'11(J�O•.••..•••.••.••• YAUDROR
�a0��i7
_ � zo _ zo
�SI�f pfOpPll`� III Q116LC11: /VIf1U8�' ASSCSSCd
❑ Real HvpeM ❑ Mnualy Assessed
Dishich I Flas this deduCan d
for aurent yeaY?
zo _ zo _
:tea m property
YPS ❑ No
�
������ZrYCQJl.c� � ��ry. �(.�� � � ��.�..�� � ��
the nalry of pe ry that the above �nd foregoing infortnalion is W e and cortect arM Nat the appiirant is a resident of Indiana arM
yer of ttie aforementioned property on date application is filed.
�) Date (nnntli. daY. Yme�)
--t— � �� __ ":t
Pelson auth«aeO M' duN exewte0
AEtlress of auCror¢ed person (number an0 stree;
ity, state. and LP mde)
�riticetu�, _� ��1Ca
w Cy IC 6L742-0]