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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township r
__, � FOR DEDUCTION FROM ASSESSED VALUATION
�� � suca wm, aa�os cR„ i s-0s� k �.
�' ,�,. f PrPSOibed by �epartmeN of Loml GwemmeM Frmnce � i
de Mark: '
INSTRUCTIONS: Fpq
To be filed in person or by mail vnN the CountyAuditor or Counry Recolder o! the county where the property is located. ry11-�� .�
Filing Dates: 7) Real PmpeAy: Must file dunng fhe year (or which fha detlucGOn is soughG Coun Audimr
2) Mobde /Manulactured Hwnes rrot assessed as Real PropeRy Musf file dunrg the fwelve (72) rtwnfhs
6efore March 31 of each year the deduction is swighL C �
Sae reversa siAe lor adtlrfional instructions arM qualdirafions. __....�. e� �niTOR
naesse� vaWe of real P�oD�Y a5 W
�IarN7 qnpftl�ar
If ro. what is h'a / het euG share ot u
If narne on iemN's Eifterent lhan iha�.
Name af rtrmgagee ar contrad se0er
KeYnumbu/le9al� ye� o�V(/V.
/ ' C.1 �
(fJ /'
or(qage / Contraa intlebted�ress unpaid a N
Martl� 1. a�rtent yesr
uMirate below.
ACAress d rtnrtgagee or contract se0er (numh�v end sbee; cdy,(state, ard i
Name of assignea w othrJ ovmer w hdAer d mortgage �
�.
��
AdAress of asvgnee (num6er and stree4 uN, stefe, aM LP cotle)
Dces appikant wm prope,rty in any other If yes, what count�?
oounry in IMiana?
❑ Yes ❑ No
NTat Ta�drg Distritf?
i
number � Page
in0ebteAne55 unpai0 as oF Is Ne app�ant Ne mle
�% Iegal w eputtade amell
7 .� � n Yes I—I No
ie Property in Ques6on: MnueOy Assesse0
Real PtoPertY Q Pumually Assesxed
Has Nis tleGUflion Oeen reQUested m pmp�sty
fw curtent yeaR
❑ Yes ❑ No
COUNTYAUDROR
De�umon aPProvM In �he amount a!:
20 _ 20 _ 20 20 20 20 20 _
Sigfanue ot Camb AuEitor Counry Date (rtmlh. daY• Y��
I I We ceNfy urMer �he penalty of perjury that Ne above and foregoing infortnalion is W e and cortec[ and ihat the applit�nt is a 25ident oF Indiana and
owner I contracl buyer of the atorementaned property on date appfication is filed.
(ovmerT hAla Date (nw'tli. daY. Yea�
i
� F rev ent aqtlress ol n� (numDer sLe ; tlL�P cotle) , ���
,/��/�%
Pe�son authp¢e0 by EWy ezeanetl Power atAttwneY ��' IC 67.7-12-0.7 Date (monM, tlay, yea�
Pdtlress of aWiu'¢etl person (numbeiarM shee; rity. slate, andLPCOde) _