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""� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
__ . FOR DEDUCTION FROM ASSESSED VALUATION
� sr� w� aa�oe (R�i i �-w�
�' ,.,. ? Presrnbed by Departrnem af L�1 Govemment Finarce
File Mark
INSTRUCTIONS:
To be filed in person or by mail wdh Ne CountyAudito� or Counry Recorder of the coun where the F��� ��
ry property is located� A �
FiPog Dates: i) Real Pmperty: Must file dunig fhe year (or which fhe deduction is wught. g ��/ .��(�, q�
2J Mo6�7e / ManuFactured Hortres not assessed as Real Property: Must file dunng the fwelve (12) rtronths
6efole March 31 of each year the deducfion is sought. r� C� ; Recorder
See reverse side 7or additional instructions and quali�cations. �
np�m(ownermwnnartbuyer-seeresfnuion�smre siYe) / /� � C.'J.M.�.-1
w/legaldesaiption '
-/?> �l—�lOD —OD 3�7-
Mwtsaea � co�vaa inaeetear�s unpai7 as or Monyage
Marrh 1, wrtent yrar date of a�
I( rp. what is his / her e�f1 sha�e of interest?
It �me m �emtl is GAfplent tlNn Nat of aPP�4 ��Cate
Nameo(nwrigageew treGSellef�
y �,
naa�or��«�,r�a��� ee�a�a
Name of assignee or other ownet or hdder o1 rtqrtgage
AAdress ot assi9nee (num6er arM stree4 mY• slate.
��� � �'�" 3
applipnt o+m pmperty in eny oNer
munryinlMiana?
❑ Yes ❑ No
Detluction aoomved 4� �he amount of.
� I �
If o-xned wiN mmeone
arNZ/Poode)
unpaid as o(
SDa+�. irMirate wtth whom
ant Me soie
ntade ovme(1
Yes ❑ No
IS M2 P�PQrtY 111 QUCSLCII: A11IW 3AY PSiCi^+CC
❑ R�i Propeny p aII,�y n�e
' If yes. whyl muntyt Wtut Ta�drg District?/ �•-
�5 tE��' �Ut�
COUNTY AUOITOR
zo_ � zo_
Counry
� a- ��� -�
I! We cerdfy urWer the penalry oi perjury that ihe above and foregoing informaGon is W e and correct arW �hat Ne applirant is a resident of IMiana arW
owner I contrad buyer of the afaemRntioned property on date applicatlon is filed.
� ...yTa,..... � .. .e.,
�
� F t aCOress W�
Psson autharrz�Gy duty
olAttwney ar by
person (num0erartl svae4 dry, sfa(e, and LP cnde)
vt��llL, �1
(monfh, day, yse�
Date (rtpnlh, Cay, ysa�
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