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r'"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun ip �
� FOR DEDUCTION FROM ASSESSED VALUATION
� sr�e � as�os (ai i i uov>
�' ,w, � P2saibed by �ePartment o( Lnral Govemmenl F�w�ce �
Fi
INSTRUCTIONS:
b 6e filed in person w by mail vrifh tAe CountyAuditw or Counry Recorder of the county where the property is located. F� �� ��
Fifirg Dates: 1) Real Proparty: Must file dunnq the year for which the deduction is sought ��� ����o�
2) Mob�7e / Manu/adured Homes rrot assessed as Real P/operty: Must fife dunng tAe hvelve (12J months � �unt�meCn�tler
betore March 37 0/ each year the deduction is swght.
G BSON i�
Sea reversa�e /or additional insWClions arn) qual�cations.
qpp6�ant( wqbnvaebuyer'�ee ^ °^(eversesifel' / l
� real propem� es ot
w�rem yra.
! her eraU share of intemt?
If rame m recad is Aitle2nt Nan ihat ot appliranf, mCkate Eebw:
Name of rtnrtgagee a mnttaG
u
snee; ury, state.
mortgage
�5 oi a95ignce (num0ei _ ' _
a��«,�� ao�a_y��y
y in InOiana? C
���,aa �o
cGOn aPPrwed'u� ihe a� �� � �., I
���S�i.i v�
20 �
SigfaMe W Counry A�Wimr
20
- — "/ (J - 7 / / r
1 az of Mw�qage I Conb2C InEebtedne55 unp3id as of Is Ihe epPfiUnt the Sde
dafe of ap Ofation legal w equitaWe rnme/1
�� ��� � ❑ Yes ❑ No
If ovmed with someone dher ihan spouse, imlicate wlth whom
�RIs property in Question: MnuaOy Pssessed
eal Pfoperty ❑ ArmuallyAssessed
VJhat Tavrg Dstri�1
20
Has Nis tletlutlim Oeen re0ue5teE on praputy
tor turRfl� y2d(.� �--i .. r-'1
20 _ � 26 _
yea�
I/ We certify under the penaly ot perjury Nat Ne above and foregoing infortnation is we and correU arM ihat the applitant is a resident o( Indiana arM
er I con4act buyer of Ne afore ntioned property on date appliption is filed. •
� wne/s!ullreme%1 I • . . Date (mon7h, daY• YgeA
PP15on
W
stare. aM
person (numbereM straet, tlry, state, aM LP cade)
Oate (rtwnN, tlaY. Y��1