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^'+ STATEMENT OF MORTGAGE OR CON INDgBT�IE�S Coun Township vear
• FOR DEDUCTION FROM ASSESSED VAL TIfDtJ�
` ' s��,,,��o�cR„�6-w> SEP 27 2�12
, Presaibed by DepartmeM of tnd Govemmerrt Finance
INSTRUCTIONS: C �
To be filed in person or by mail with the CounryAUditor or Counry RecoNer o/ the counry where�t(�g " rty is located.
Fifirg Dates: 1) Real PropeRy: Must 61e durirg the yrear /or which the deduction is sought. n��R� p
2) Mobde /Manufactured Homes rrot assessed as Real Prope��(3(.fi,@OkiAl��e [ovEive (12 months
6etore March 31 o/each year the deduction is sought.
See reverse side (or�Uitional instnictiuns and qualifications.
MP�m (a m buyer'see re:�liyrei m ye. sitle)/ �l _/l � �
�.�..�..�
share oi in�?
m remtl a 6ReRnl than thal of appGran� uW'uata helaw:
Nartre ot mortgagee «mntrsG seller
Mdress of morc9a9ee ar
Name of assignee w otlrer ovmer or Imlder of mvt9a9e
,��----�— �Ru11aLP p
� j �2.�� M� �
�� (�',6GN/� �
state,
Odu /{/�' �� ��
Sigra o(
I/ We certify unCer ihe penalry of perjury Ne above arW
owner I contraa buyer of ihe afwemer�tioned property on da
of
person (num0erarMSbee(tlry,state,
File Mark
Form Ned ' .
County Auditor
❑ Counry Recorder
�(. �-o-oa1� �b� �a�o
as d Mortgage / ConVa(Y inCebtetlness unpaid as d Is Ne epp6rant Ure sole
dale of aOP�� legal ot cyuitade ovmer+
� ❑ Yes ❑ No
tt wmed wiM someone dher ihan spousa, udicate wtth wfiom
)UNTYAUDROR
20 20 _
Caunry
Is iM praperry in QuesGOn: Mnua9y Assessed
❑ Real PmPenY ❑ ?!m!�Y �
��es�ea m v��r
❑ Yes ❑ No
20 _ � ZO
Date (month, day,
infortnalion is true and cortecl and tha[ the applirant is a resident of Indiana and
ion is filed.
Date (rronfi. daY. Y��