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^'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
__ ; FOR DEDUCTION FROM ASSESSED VALUATION
se� w� a3�w cR„ � sos�
,»�. � ResrnDed q Departmenl or Lora1 Govemment Firenca
INSTRUCTIONS:
To be filed in person a by mail wiN fhe CounryAudifor or Counry Recorde� of the counry whe2 the .
FiNrg Dates: 1 J Real Properry: Mus! fde during the year for which fhe deducfion is sought.
2) Mo6de / Manufactwed Homes not assessed as Real Praperty: Must h7e dunng the tweNe (72� �nff� s
6efore Mamh 37 of Bach year the deduclion is sou�ht.
See �everse side for adtlitional instrucfbns and qualifications. �. ,_ ,
:u• �.o�i
wrtent yeer
If ro, whel is his / her PXatt Share of
rwte m mmrd'a diRemnt Nan Ihat of app&an; mdicate bebw.
Nama of rtnrtga9ee or mntract se0er
Mdrea of mut9a9ce or contra�i
w oNal owner m Iw
uoes eppuam o.m pmperry m any
couNy in InEiana?
❑ Yes
DeducGan approw-0 In Ihe amount ot
20 _
Sig(a4rte W Co�mb Auditw
�_
.E='3
County Auditnr
Caunty Recarder
unpaid as of Morigage / ContrafY uWehtedr�s �mpaid as d Is Ne appikant the so�
date of appfrcation legal w eQuitade oxnM
❑ Yes ❑ No
If awned vriN someo're ather than spouse, Indicate with wlrom
rtwrtna��. - - _ � Q
r Q��-, �,.5.......
Dra�vcr \0..... �
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Caid N� . ............
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2p 20
Counry
20
Is Ne property in Que55on: MnuaOyl�ssessed
❑ Real PfoPenY ❑ ��!aM�
�i351�16 dCdUC40f1 GfCll RQIICSiL'd IXI pfO�Plly
fm arrent yeaR ❑ Yes
❑ No
20 _ � 20
oa� (.,,o�u�, day,
I I We certify under Ne penalry of perjury Mat lhe above and (oregoing infortnation is true and correct and Nat ihe applinnt is a resident of Indiana arW
owner I mntrad buyer of ihe atorementioned pmperty on date appliralion is filed.
�reLre UG},er's hID remal _ / Date (monN, daY Y��
of appt�nt (numDe�,qd s1reeC ciry, state,
or by IC G7.1-12-0.7
Pdtlf¢s of aWiwved person (number aM sbeel ary. sbte.
�Y. Y��