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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship Year
,_ _ FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 93709 (Rti / 6-W )
,,,,, f Presaibed by Departmant of Lval Govemment Fu�ance -
File Mark
INSTRUCTIONS: F� �� �.
To be fiied in person or 6y mail wiN the CountyAUdito� or Counry RecoNe� 01 fhe counry wh�the perty is IorafG�
Fil'mg Dates: 1) Real PlopeRy: Must file dunrnJ the }rear for which fhe deduction is sought. q� Lu,u � Counry Auditnr
2) Mo6�7e / Manufactured Homes not assessed as Real Property Must file during the h�i�QJ�dhths ❑
before March 31 0( each year Ne deduclion is swght County Recorder
f�
See �everse side /or additional insVUClions and qualifications. ,�,�„ , � +°'%f ' _„
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MazU 1, mm�l year
tt rw, whal h his / her exact stiara of interest?
Nart�e
m remttl is Qdferent Ihan Nat
,���
w oiher owner or hdder of matgaga
AGCress of assignea (num6er antl stree4 �Y. state.
Dces epplimnt rn�n property in any
countyinlnCiana? r—� ..
amount of.
20 � 20
��_ �v-l1oi�.3o-oa�
/ ContraG'udnbtedness unpaid as o( Mor�qaqe / Contrac
arten[ yeer date of appfmation�
It yes, wnat �
No
20
H ovmed vriN someone
aM ZIP code)
unty? WhatTad(gD'aV
COUNTYAUOROR
20 _ 20
Caunry
��as o( Is ihe appih�ant the sde
legal w cquRaWe oxnel?
� ❑ Yes ❑ No
spouse. iMimte with whom
Is
perty in qurstian: MnueOy Assrssed
ProPeRY QArmuallyPSSessed
Mod1e Home pC 6
'__— �;,;:1.'�
..
Drav�'er \ ..... .
Card \O. .....�!.`Lnc•!......
� ��a� U��� L�
20 � 20
�Y• 1��
I I We cer�fy urWer ihe penatty of perjury that Ne above and foregoing infortnation is We and correct and Nat the applirant is a resident of Indiana arW
owner I contrac[ buyer of Ne atoremerrtioned property on date appiication is filad.
autlioraetl by dNy executetl Pwer
�
w
Pddr�s of authomed person (number aiM sbee; dry. sfate, and ZIP tode)
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