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^'*v STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
�_ _• FOR DEDUCTION FROM ASSESSED VALUATION
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S���. pr�v,'n�a M oepar�rek o� wm co�mmene Fu,srce
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wsrnucnoNS: e�ryry
To 6e filed in person w by mail with the CountyAUdilor o� Counry Recorder o/ fhe counry where the property is bcated. N FOf� ��u �Z
Fi7irg Dates: 1J Real Pmperty: Must file during the year (or which the deducfion is soughf. � Counry Audimr
2) Mo6i7e / Manu/actured Hortres not assessed as Real Property: Must fife dunng the hvelve (12) months �-
6efae March 31 of each year the deduction is sought. - C- � M�iCEii nty Recorder
Seereversesi�(oraddiGnnalinsWCGonserMqua�trons. , \\QiiniTnR
MPfrant (o coritra� A�ryer' se9 re� � e) n � .0 1 � .... � _ _ _
Taavg District
Ar.,�sed velue d real property as N
MarM 1. ameM year
rc no, what is his / her e� share ol u
If name on remrd is 6Rereni than Na'
Name of rtwrtgagee or contrar� seller
Addres ot momJa9ee w mntrad se0..
Name af assi�ee or othu owner w h
AOtlress oi assignee (numbe� aM stn
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Ma ge / Contrarl Ndebtetlness unpald as of • Mortgage / Contra<3 iMehtedness unpaid as of Is Ne appfirant the sde
date of appOratun kgal or equitade o.merl
� ❑ Yes ❑ No
If ovmed wiN wmeane other tlan spouse. i�Micate with whom
m«tgage
state, anCi
Ooas app6ran[ own ryoperty in any oNer I Y
munry in IM"au? ❑ Y25
❑ No
�_ , �
Is ihe pfoperry in question: Mnua�y Assessed
� Reai PfoPeKY ❑ %v�n�a�h1 Ase�ed
city, state. aMLPwde)
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S/'E+�.� J xarmntY�R
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requested on P�W�Y
❑ Yes ❑ No
20
sigreme a co�mN nuciwr I counry I oa'e (mowt dar, yea�
I I We certify uMer the penalry of perjury that Ne above arM foregoing infortnalion is true and mrtec[ arW that Ne appiicant is a resident of Indiana aM
owner I mntract buyer of the aforementioned pmperty on date application is fiied.
Si9 _( fiLl^a^� /� Date(rtmfh.daY.Y�+)
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Pe�sw� aufho�'ved by EWy rsecuted Power af Aimrtiey w Dy IC 61.7-12-0.7
Pddress of aufhw¢ed pe�.,on (numDerantl sneeG c1ry. sbte, arM LP code)
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