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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__ FOR DEDUCTION FROM ASSESSED VALUATION
� �����,R,,,�> F I L
�,,,, � rresa;nea by oea��� m �om cwemmem Fu�
File Mark
wsrRUCnoNS:
To 6e fiied in person or 6y mail with the CounryAuditor or Counry Recorder o/ the wunty where�p p�pye�tyri(�q�ted. F� ��
Frlirg Da[es: 7) Real Pmperty: Must file durirg the year for which the deduction is soughG J V` �+ 1 L°" Counry Audimr
2) Mo6ile / Manulactured Homes rrot assessed as Real Property: Must fiie dunng fhe hveNe 12) months
6efore March 31 of each year the deduction is sought. C.`J_ � ❑ Counry Recorder
See reverse side Ior additiynal inslrucUOns and qua/ficatbns. �
T � I��iStriU KeYtw
�
Assesse0 edmalqapenyaof
Ma�di 1. ymr
�� fq. W�ld� 6 �16 � iC! EY2C15�IdR Oi Il1�2R5��
If rwne on recoid is Eilferaft Nan that of appl
r/regalaesrnpWn Recordnumher Pagen
- a-- S9 - 3 a-ooa. 3is - o�t f �
�9a9e / Contra�x indebtedness Unpaitl as ot Mortgage / ContrarY inAa�.rw,� �mG� az o( IS Me aOP�t Me eN°
Marrii 1, arRnl Y� date of ePP�� �� a��e �
❑ Yes ❑ No
tl owrred wiM someone dher Man spouse. indwate wtth whom
4�dinte Gebv` Is ihe properry in 9�e"�: �nua0y Assessed
❑ Real ProPerty Q Mniiali�i Asse�d
Name o( mMgag or oDntract se0er �
Mdress of rtnrtgagee w cvnVact seAer (number and sa
Name of assignee or other owner or holder of rtnrtgage
ACtlress of asskyiee (��r aM stre
oces appliqM ovm property in any ot
munry in Ind'ana?
❑ Yes
DeducEon approved'm �he amouN of.
20 _ 20 _
Sigfa of
I I We ceNfy uMer ihe pena��
owner I mntract buyer ot the :
cdy, sfate, aM ZIP code)
K�� �KEC��
I I -.�u3�
of appfrcarit (n�
s (LY
GWy esewteE Power otAttort�eY w Dy IC 61.1-12-0.7
I person (numberarM sbee4 �y. stete. aM ZIP oode)
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