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.s'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun wnsh Y r
FOR DEDUCTION FROM ASSESSED VALUATION
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S � ������,�����,���,�F��� OCT 200
HM
File Mark
INSTRUC710NS: � `�y� �/�
To be filed "m person or by mad wrfh tlre CourrtyAudRor of fhe tounty where the property is bcafed. p'/a �1 ��+°�
Fding Dates: 7J Real Property.� Dunng the 12 rtronMs be(we June 11 0/ the year the deduction is to be aOecbve. C/ U
2J Mobile Homes assessed m'der IC G1.1-7: Behveen January 15 and March 2 o(the year the deduction ia��9��fl�$�TY AUDITOR
See reverse side for additional insWctions and qualificafions. �
- see resMCffwlf m revcrse
Taidrg DisUid Key number / legal pUon ' Rewre number Page number `
-i � - - �oo - oo�. sy8 -o� � y3 �.,
As�u.d ot real as of Mamh 1, amnl y�r Mortgage I CoMfaG indebiedness unpaid u of March 1, Is Ihe appG�nt Ihe sde legal w equitaWe o+me(7
anrart year /D � O O
❑Ye5 ❑NO
If - 'ul is his / her exad share a( iirte2st? If mvned with sort�eone dher ihan spouse, indicale with whom.
If reme on remrd is d'rfFerenl �han Ihal of applicaM, iMimte below: Is Ihe property in question:
❑ Real Pmperty ❑ Mobile Harie pC &1.1
Nartre of morigagee or cmtracl seller �
ndd��s m motiy�� «�,uaa s��er (numce� ar�d srreac aN. �a�a, ar�a z�a code)
Nama of assgriee a ather oa�r w hdtler ot mortgage
Address of
munH'�m 11r
ZIP code)
poperty in arry other If yes. what courriy?
❑Yes ❑No
Deduclion apprwed in �he amoun
20 � 20
r
Signature of Counry AudMr
NR�atTa�dngD"u ��'" " •��( / �O(f�,` ..�^,^�D�,
SuE71,ey K
COUNTY AUDITOR
20 20 20
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�y
I/ We certify under the penalty oi perjury that the above and foregoing infortna0on is true and mrtect and ihal the appGpnts xas / were a resident of
Indiana and owner of the aforementioned property on Marcn 7, 20 '
uahve (o ers rwnel / . / I • A/ Dale (mx+Ih. daY. Y��)
Permn
cdy. state.
At�orrrey of by IC 67.7-12-.07
af auUqraed pe,son (number a� sheef. ctiy, state. arM LP
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