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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS o n ip Year �
� FOR DEDUCTION FROM ASSESSED VALUATION
State Fa(m 93709 (R71 / 609)
S,,,, Presaibetl by Departmen[ of Loral Govemrtrent Fuiarce
iNSrRUCnoNS: SEP 2 �'���
For�Bed with:
To be filed in person w by mail vnth the CounryAuditor or Counry Recortie� o/ the county where the property is located` �_ �°`-�y-'''�
Filirg Da[es: 1) Real PropeRy: Must file durrrg the year (or which fhe deduction is soughL � cC,aunty Auditnr
2) Mobile / Manufactured Homes not assessed as Real Pioperry: Must file dunng fhe (welve (12J months V
6efo2 March 31 of each year fhe deduction is sought.
G�BSON C UN Al9Hi�Tit�Rtecorder
See 2verse side for additional insfructions and qualifications.
see resvi^ypns rn reverse
legal
�������o�
Mardi 7. uumnt yrvr
�- o - ce 5� �'�-oa %
�/ Contract 4dehtednrss unpaid as of Mwtgage / Contract irMeMx
Curten� year date of appGfation/�
If ra. what Is his / her e�d share of intemstt
If name an rtmtl is dAfer�nt Nan Nat o( appGqnt, uNitate 6elovr.
Name of mortga7ee or mntracl seller I%`�
l
Atltlress of rtwrtgagee or anVacl seller (num6er aM streel, ciry stafe, aM ZIP code)
Name of assignee or oUcer ovmer or holder of rtnrtgage
Atldress of asvgnee (number and stree( lriy, state, and ZIP cotle) /� , �
ces appluant ovm pfoperty in any olher I If yes. what munty?
wnry in InOiana?
❑ Yes ❑ No
Record number Page number
unpai0 as of Is the appfirani the sole
legal or equifade mvneY?
� GG ❑ ves ❑ No
If owned vriN someone other than spouse, indicate with wiwm
pmperty in question: Mnuallyl�ssessetl
�� aopertv ❑ tvmua�y Assessed
ia -� - /6 / a.�� �
ig District? Has �h5 deduction Geen requested on ptoperty
for artent yeaR � �
COUNTYAUUROR
- D�-�„ �,-.�o...��a
. . .: . . . . . . . .. 20 2� _ 2� 2�
; C:j I�d � Q. . . R � ��.. . . .. . . . Counry Da(e (nronth. daY.Y��
� �157,5���'
I foregoing infortnation is true and cortect and that the applipnt is a resident of Indiana a�
owner / contract buyer of the aforementioned ptoperty on date applira0on is filed.
re(o1me/s lufl name) � Date (month, day, yea�
��Q.� �iT.CI�
Full resident address of app�rant (number arM dty, state, arM LP cotle) /�
3o�7O � SU S CiY1CPfUt1 �ii/ �Ei�O7O
or
P.tltlress of auNor'ved pe+sw� (numberand street m1: stale, aM ZIP mtle)
Date (rtronfh, tlaY• YEa�