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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
a FOR DEDUCTION FROM ASSESSED VALUATION
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INSTRUCnONS: Fle Mark
To 6e filed in persm or by mad with the CouMyAudROr d fAe county where the properiy is located.
F7urg Dafes: 7) Reel Propel(y: Must 7de durn/g the yea�lor which the deduction is sought.
2) Mobite / Manulectuied Homes not essessed as Real Pio{rerty: Must file dunry tlie fweNe (12) mmfAs 6elae March 31 0/ eaGt yea�
the deCuction is saght.
See reverse side lar addiTional insWdiorts arrd 4�lifications
App(ranl (owne` v mrdracf - see rtuDiefians m mwise side) �.( �.
/T p� r �
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T D'abicf Key manher / lagal desaiption � papa ��
�'1�,.-,�' �i_i�-oi-3ao-cb/.�5, -oa r � /�4
as
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Y ro, what is his / her er.ad share d iNerestt ' � If owned rilh someo�re Wher Ihan spouse.
G iume on reartl is GdfereM lhan Ihat of a00�. intlimte belw.^
mortgagee or
d au9�e w o9ier owner or tdder d morlBaBe
Pddress d asi9nee (numDe` an0 strerl. cd1: ffib. and LP meo)
Does avW�a�t awn popeny in ary aaher
couMy in Irdta�7 r'� ' _
v� u No
1s �he D�PeM in CueGion: MnuaN'Assesmd
❑RealProperty QMnuallyAsessed
Mobile HomellC G7.
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COUNIY AUDfTOR
DeAuclion aGG�a'� � Ne amouM d-
ZO 20 ZO _ 20 _ 2q _ 20 _ 20
Signat�ra d Co�myAuEitar Counry Date (mmth. day. y�
1/ We certify uMer lhe penalry of perjury Mat the above and foregoing a�fortnation is true and cwred and that the appticant is a fesident o/ Indiare antl
owner / mntrad buyer of Ue afarementioned poperty on date ap0��n is filed.
�" nature RM ) // 1 Date (momh. daY. Y�'a)
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F W rasidanl address d appGwnl (�n �� ad M . and ZIP ooao
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Person authwrzeE by duly ezecvteE Pawer af Atlomey w by IC 6-1.1-12-0.7 Date (maVh, day, year)
PGtlressdaWhotizedperson (nionberandsGCOt,city,ffife.anOZ/Pmtle)
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