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� STATEMENT OF MORTGAGE OR CONTRACT INDI
_ FOR DEDUCTION FROM ASSESSED VALUATION
s� F«m a,�w �Re i 2-0n
�' Presrnbed by DepartmeM d Locai GovemmaN Finance
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INSTRUCTIONS: �
To be filed in person w by mad with the ComdyAuditor d the courtty whera Me propeRy is bcafed.
Fding Dates: 1 J Real Roper(y: Dunng the 12 months 6e(ore June 11 0/ tAs year the deduction is to be e/(ective. %%J
2) Mob/7e Hanes assessed imder IC 6-1.1-7: BeM�een January 15 end March 2 of the yeai the deductim I� t6 �' .
seereverseside�oraddmw,aiinsavcmnsaneq,�rrcasons. elqaQN C�NTY AUDITOR
^ see reshfc6onspn raverse
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Assessed raiue o( real PW�Y as d Maich 1. a�rent Y� �Ba9a / ConUac7'uWebtetlness unpaid as W March 1. Is Ne
°'rt�°'�` 89 n��
Name ot rtnrtpagee or oonUad saller
Address ot mongagee n
IX
Does appliranl o�m puPartY in arry other
COUItIy Ol �lldpll8%
❑Yes ❑No
Dedudion approved in Ihe amauH ot'
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i�ote 6elow:
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dfy; sfate, antl ZIP code)
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�f y99. W�IB� WUflm
sort�mne
- D 1:� \�'t
w�t r�ana t
spouse,
Remfd rambar Page number
04 d /!� !c
&fanf ihe sde legal n equitable o+rt�el,
❑ Yes ❑ No
Is Ne prapaM1y in yueslim�-
bme (IC 61.
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5,�,��
� Cal'Cj ���
COUNTYAUDITOR �
20 20 20
Caunly , . <y.
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I/ We certify�iinder ihe penalty �perjury that ihe above and twegoing infortnatbn is We and corred and that Me appGpnts was / were a resident of
Indiana and ovmer of fhe aforementioned property on March i, 2b
7�adre (owners hdl name}., ' Dale (manth. daY• Y�A
streel, aty, stafe, and LP
person (numberandsheeCrdy.sfafa,aMLPwde)
Oa1e (monfh, Jay, yeaA