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"�+ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS , s ipl Year
FOR DEDUCTION FROM ASSESSED VALUATION -
.� s�a ra,,, aa�os �ras i zo�> 5�LUU1�
�' ,.� � r.asa�bea br Depanmeni w Laa� Go�emman F�r¢e NOV
INSTRUCTIONS: `�J ��3""�l•�
To be fiied in person oJ 6y mad with tfie CourttyAuditor o/ the county wheie U�e proper(y is bcated. ��
Fd'v,g Dates: 1 J Real Property: Durrng the 12 months be(ore June 17 W[he yea� Ure deduction is to be eHective. cnvN COUNTY A ��TOR
2) Mo6ile Hanes assessed under IC 6-7.1-7: Behveen January 75 and March 2 07 the year the defBi��S fo be eflective.
See reverse side /a addiGonal insWctions arid qualifirations.,. -
/Wd Wwrivarmnhad6uYer-sOa$9r�timsmreverseside) n
popaty as d Mart�h 1. artent y�r
whal is his ! har exad share ot iMemsl?
recad
Oi IfqI�Q39CB IX WfiNdd SCI�C!
e�a-��r_-c
arM.�eet dN. sfale. and
Nartre of ass9nee or dhet oxner w hdder of martgage
Address of assi9rrea (mmrber arM s6aet. cri�: 9a(e, end ZIP oode)
Does applicant own poperty in arry olher If �es. whal camly?
cauruy in Indiare7
❑Yes ❑ No
Deduction approved'u� 1he arnwnt of:
20r� 6 20 20
v ��—
P
Signature ot Caunry Audilnr
�
COUNTYAU
Recard number
:�tli��l� �G
�
someane oUrer Uian sp�wwse, indicate vrifh whom.
« eq�made ownen
❑ Yes ❑ No
Is the propeM1y in quesUm:
❑ R�I P�opertv O Mobile Home
DrawerNO...°S�••••••• �°^a°P°o'
5�/ ^� 'es ❑ No
l�
Card \i �� '
. .......7.� ....�
�rn &�a-, ��c:��.�,) rr�`"j �p.
20 I 20
�
20
20
I/ We certify under the penally of perjury that the above and fwegoing infomiation is We and correct and that ttie applicants was / were a residenl of
Indiana and mmer oi tlie aforementioned property on March 1, 20
��t�ae (owne(s Iuli name) _ Date (manM. daY. Y��7
lent addrms af applicanl (num6er and s8eet dty, sfafe, an0 LP wde)
511 N rna.l t�. �TQ ra � r,h
Power of Al�aney or by IC 61.1
aultar¢edpe+son (numberaMs4ee;
i�
Dale (month. day, yean