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"� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
_ FOR DEDUCTION FROM ASSESSED VALUATION
.� Srace w�m aa7oe IRtt / s-os)
�' PresoiEed Ey �epartmeM of Loml Govemmant Frence -
F'
wsrRUCnoNS: ey
To be filed in �
person or by mail with the CountyAUditor or Counry Recorder ot the counry where tAe pmperry is located4 P R � L
Fi/ing Da[es: i) Real Pmperty: Must file during the yrear for which the deducfion is wughf. � County Auditor
2) Mo6Be / Manufactuled Homes not assessed as Real Property: Must file during the twefve (72) months
6e(ore Ma�ch 37 0/ each year Ne deduction is sayht. `?-r, �I ���Y Recader
O'/
See �everse side for additiona/ instruclions and qualfirations. �,_ __.,
nssessm raWe d� po�cy az m MorIp
Mert3� 7. airerM1 Ymr Mam3
�� what a hts l lcer erarl share ot intemst2
M name on iemN is dmuent tnan ihat o! app�ant hMu
Name of rtiortgagee or tract se0er �� �
Pddress d rtnrD3agee ar contract se0er (num6r� end sL
Name of assignee w dhu owner or halder of mortga9e
Add2ss ot assignee (num6er ard stree4 �Gy, stefi. ena
Dces eQp6laM a«n property in any aner
munry in Ind"ana? ❑ Yes
❑ No
De�umon avwareE'v� tlre amouN at
20 � 20 —
��. ��� VR (�
Cantrati irde6teEnaca unpaid es W Mortgage I ConttaR
ure�rt year aate of appGcstion
sorrkone
cdy, sm�.
Reco(d rnimber Pa e qu
btedness unpalO as d Is Ne app�ant Ua sde
lepal or eQUltade oxneR
❑ Yes ❑ No
spouse. indkate wMh xlvn
Is Ihe propercy in awsuon: Mnua%ASSessed
❑ Real PropeAY ❑ �!?ivally Assessed . . _
LPCaOe) �
,� 6
�f yes. `nh3t mum�? G� O 1 O_ ,' 1 �' �V�esud on p�opaty
�/ ❑ No
�
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1! We certify undrs Ne penatty of perjury that Ne above and foregoing infortnation is We and cortect arM that the applinnt is a resident ot I�iana and
amer I contracl buyer of the aforementioned property on date appiication is filed.
annue rownels MI namel . Date (mmth. deY. Y��
�Y �Y ezewtetl
aritl
IC 61.1-12-07
persan (number aM sbee4 �Y. ��. antl LP rode)