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"n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
_. FOR DEDUCTION FROM ASSESSED VALUATION .
� sr�e r�,,, as�os (an i s-o9>
� yr r PresCiEed Ey DepMrtieN of Lod Gwemment Finente
Fle Mark
wsrnucnoNS:
To be filed in person or by mail wiN the CountyAuditor or Counry Rcrnrder o/ the county where the property is F m
Fdrrg Dates: 1) Real Property: M�st file durnig Ne year for which the deduclion is soughG � ���
2J Mobde / ManulaUUred Homes rat assessed as Real Property: Must Ae dunng Ne Avelve (12) monfhs
before Maidr 37 0( each year the deduction is sought. �^ �
See reverse side for additiunal instnicGons e qualifications. �
Apofcant nwponbaC 6u�p see i. /1 �.1 I�) �/ m . A �Fii H� V TK/
\ 4n / /_
Tatirg Distria
`wm6el
U -- /�V �" Q "� -� a UIC OA CV'UN7� ' 7
�ss¢p �ah�c d real qop¢rty aa ol Martpag e/ Contraa 4de6teEness unpaid as of Matgege I Con�C in0ebteCness unpaid as d �s ihe appikant Me sde
md� i. a�rmt ym Ma� t, arrent yeer Oate of aPP�� Iegal a epultade ovmeR
00 � ❑ Yes ❑ No
ro. what is ha / hn exaa sl�ara ol inirlest? H owned with :.ameme ahm Nan spouse. mdrate Wth wMm
tlut W appOCan4 ��� ��' Is Vie pioperty in Qursum: Mnueoy Assessed
❑ Real Propetty ❑ Armually�ASSassed
o( mortpagee or fnntau se4u
Pddress N man9a9� m m�baG se�er
Name of assignea or other awner ar MiGer m'mtgage
cIIy, sple. erd ZIP cada)
Dra��•er \'O...aOlb
Ooes applicant ovm Woperty in eny oNer If yes. whet munp? lMiat Tari� Distriri?
munry in Ind'ana? ❑ Yes ❑ No C� I'Cj �iO. .. a S. ( ip
. ........
COUNTY AUOROR ;� 9 y��� 5�a � U v
Dr�uclion apyoved in Me amount af: V
20 20 29 20 20 _ 20 _ 20
Sig�nne N Counb Autlitw Counry Date (nrmRi. daY. Y��
I/ We certify urWer tha penalry ot perjury Ihal the a6ove and foregoing infomiation is trve and wrtect and Nat ihe applirant is a resident of Irniiana arM
ovmer / mntrac[ buyer of Ne aforemen�oned property on date appluation is filed.
Siv�aeuelowners M1Arumel Date (monN. daY.YB87
appficant (num0er anE sveet GN, �te.
w.
Persm auNa'ved W dWY exewted Porer of AmmaY a Dy IC 61.
person (numDer and SbeeL �; sbR, anA ZIP oode)
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