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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmship vear
.—
; FOR DEDUCTION FROM ASSESSED VALUATION
s�ace � aa�os �i i i �os> Te
�` ,,,, ` aresa;cea nr oepartrtcm or Lm� cwemRrent Fuwice "
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INSTRUCTIONS:
Fortn f�ed wNh:
To be filed in person or by mail wifh tAe CountyAudito� oi CAUnty Recorder of the counry where the property is located. O�����ry
Filirtg Dates: 1) Real Pmperty: Must file dunng Ne year for which the deduction is soaght. Audiwr
2) Mo6ile / Manufacfured Homes not assessed as Real Property: Must fi/e dunng fhe hvelve (72) months
befo�e March 37 0l each year the deduction is sought. C. , .� ounry Recorder
See reversa side for additional insVUCGons and qualificafions. v\
Ta�d istrid nunCU / legal desaiption Retortl numbel Page numbnl
�aJ a� - ll-1 - oo - po3, 69/- o.t � �a/,� 5 39 7
Asgscd va4e dreal P�P�Y of Mwtgage/ Contraa inde6tedness unPaid as U Mwlgaqe / ConbaU inEeMedness unVxid as of is Ne aOP�nt Ne sde
MarU 7, avrent year MarU t, arteM yeer dale of ap legal w equitaWe ormeR
O O O ❑ Yes ❑ No
I( iw, what's his I her exaU shara of intuast? If ownad vriN wmeone er tlan spouse, ifMimte wXh whom
Ii �me on �ecwd is AiRerent lhan Nat of appfrant, uidirate 6ebw tM perty in puestion: MnuaOy Assessetl
Real RoPenY ❑ ��Y�
�Aotv7e FlornellC 61.1-i
Name of rtnrt9a9ee or conttaU seller ` — - �
�J �/...w
Pddress of nwrtga9ee w conbact u0er (nurtibu and stree4 �/y. s+a+e.
munty
:(numOer aM atrfeL tlry, sfate, aM Z�IP�. cotl/e)
I ,(�(�C�
property in any olher If yns, wh:
❑ Yes ❑ No
20 20 20
Sig�unne W Co�mb nudimr
I/ We certify under fhe penalry of 'ury Mat [h
o�mer / mntracl buyer of the aforementioned p o
y re efsfNlnerm� � �f � �^�.CS
�� �,vN 1�10 A /! �F�� v/ I"/
2� � 2�
e and foregoing infortnalion is We an�
on date applicadon is filed.
PrJSOn authoraed Dy dWy rsewted Porer of AtOOmey or Dy IC 61.7-12-0.7
Address of auNOr'¢ed person (numberaM sbeet �ry, sb(e, and LP code)
��
� ' /
s Nia � Eeen requesteE on propeicy
�� ❑ Yes ❑ No
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