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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
: FOR DEDUCTION FROM ASSESSED VALUATION
� suce w�m aa�os cR�i i s-w�
�' Presaibetl by Department af Lnol Govemrtrent Fuunce
INSTRUCTIONS: m
To 6e filed in F� �1011
person w by mail with the CountyAuditor orCounry RecoNer o/ the counry where the property is located. M�{ l�
Fdirg Dates: 1J Real P�operty: Must fJe durng the }rear /or which the deduction is so�ghL �[;ounry Audimr
2) Mobile /ManufaGUmd Hanes rat assessed as Real Proper7y Must file during fhe twelve (12J monthsC �
6efore March 31 of each year Ne tleduclion is sdght. unry Remrder
See 2verse side (oraddi�ional instnicUons and qualifications. _ �,,,,��, __
iRlat 51V5 / 112! Elf2tt Share of int¢n
B m remrd 6 QAteratt N3n �ha� OI �
of mort9a9� n cmtrarl se0er -.
rvnn0er
Abrtpage / Contraa i'dehte0�ss unPaid az d MoM9a9e / l'•ontraG 6debteMess �mGaitl as W Is Ne e00�� 1he sole
Mamh 7, wrren� yeer date of app(rcation legal or eQuitade o«nell
❑ Yes ❑ No
If owned wiM someorre oUcer Ihan spouse. Indimte wiN M�an
Mdress of nqrt�jagee or wntraa se0er (mmber end sba+�-"'
Name of assignee or othe� ^�.. -
AAdress o/ assignee (numD � ��i11�}v" • �
�J
Daes eGdit2ntovm MoPertY � \�
munryinlMiana? � ��\ �/�
� `
Deducson aPPmvad'ei ihe amaui
20_ � p- � p-
1/We
0
COUNTYAUOROR
20
Caunry
Is iM property in puestim: Mm�eOy Assesse0
❑ Real Properry Q ArmuallyAssessed
Oistrict? I Has this deduCion b
for airtent yea(.+
20 _ 20 _
stea on propvty
Yes ❑ No
Date (moNh, tlaY. yea�
20 _
under the penalry ot perjury that the above and foregoing iniortnaGOn is we and correa arW ihai the applicant is a resident ot IrMiana ard
act buvu of the aforementioned Droperty on date aoo��cation is filed.
Pawn auUroraed GydWy
D�
antl LP mtle)
61.1-12-0]
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