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^'r STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun a shi r
__ • FOR DEDUCTION FROM ASSESSED VALUATION
" ' sm�a F«m aa�os �an i sos�
' w� j Presrnbed Dy �eP�ent oT Laai Govemment Finarxe
INS7RUCT10NS: ��a� �O'�
To be fiTed in person or by mad with the CountyAWito` or Coun Recorder o/ the co�n where the F�" ����
N �v woxm � ro���. c.�
F�tg Dates: 7) Real Property. Must file dunng tfie year for which the deductlon is soughL � �
2) Mo6de / Manufactured Homes rrot assessed as Real Properly: Must fiie during the hvelve (72) months n C NR
6efaeMa2h31ofeachyearthedeductionissought. � GIB ON'60�ry�qy
See reverse side for addrtional inshuctbns end qualifications.
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It name m RmN b Qrtfrlent Uan that of aOpGCaM, iMwate
r�r� m rtrorteayee «
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/ Contract 4Wrbtedness unpaid az of
w rvntracl srder (num6er end sbee4 GN. ��. aM LP code)
w otlm! ovmg or hdd� N mortgage
AE�ress of assgnee (number arM stree( cti}; stete, aM LP code)
� a � oZo29 /(�, °s'�
�� ._ Dra�ver. NO. a�!� �
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c���d ��o. ...589� "
Siyriame m Coimry Audcnr
Ii
- NTai Taritg Oistrict?
;OUNTYAUDROR
20 _ 20 _
Counry
' D� �/ Remrd num �� Page nu �
j C.
:onra�t trMebieEri�ss unPad as d Is the aPP�anl Ne sole
�/'1 /�?�� legal or eQUita6le vmull
' (1'1(' / R (I Kl ) ❑ Yes ❑ No
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rame nc s
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Has Nis dedWion Deen re4uesteG m P�Y
� �� �� ❑ Yes ❑ NO
20_ ZD_
Da�e I�. daY. Yea�
I I We certify under ihe penalry of perjury that the above and foregoing infortnalion is W e and correct arid ihat the applirant is a resideni of Indiana ard
owner I wntracl buyer of the aforementioned pmperty on date appfication is filed.
mawra ers f�f name) . /� Data (rmnfi. day, Yee�
��.
author'ved
AdCr�ss of authaaed person (number arM strae4 uN, sb�e. aiE LP cnde)
Date (monfi, daY.
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