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^'� STATEMENT OF MOR7GAGE OR CONTRACT INDEBTEDNESS Coun Township vear
_ � FOR DEDUCTION FROM ASSESSED VALUATION
�• State Fwm 0.1709 (R71 / 6-09)
�' � Presmbed tY OePa�nt af Lacai GovemrtreM Fuarice
File Mark
INSTRUCTIONS: F
To be h7ed in person or 6y mad wifh the CounlyAWifor or Counry Recorder o/ fhe cnunry where the property is located.
Frling Dates: 1) Real Property M�st file dunrg the }rear (or which fha deduction is soughL C� Audrtor
2) Mo6ile /Manufadured Hwnes rrot assessed as Real Ploperty: Must file during the hvelve (12) months
before March 31 oteach year the deduction is sought ❑ � �
GIB
See reverse side lor additional instrucGons arld qualfiwtions. � UDI70R
e �J..,.,.m.....�.��r,� n.�.o� �w� m.d ' �.vi mw.�.. �:Iav� i •
" Disfirl /' Key n t� / legal desciptim
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As�ssa7 raWe a1 real yoperty a d ge I ContraG'v
MarU 1. aa�ent year �i, artent yenr
H m, what is tis I her e�a share ot interestt
If name on remd s 6Rerent t7wi ihat ol aPp6can4 udinta 6elavr.
Name af mortBa9ea or mnttaG seQU Q q�
J!//�.Y l
AEdress ot mort9a9ce w mntrad seAer (numbe� and shee�'r�y, s a , ard �
Name of assignee or athu awner ar hdder of rtprtgage /,
i
(D
AECress of assignee (numbrr arM snee4 G4: �e, aM LP oode)
Ooes epPlimnt ovm property in any other If yes. wha[ wunty7
munry In �ndara? f'l .,_ _ I—I .. _
Deduction approveE In tne amount
20 � 20 � 20
ZO
m
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w equitable ownPY/
❑ Yes ❑ No
�Is prapertyinquestion:Mnualyfv�sesse0
Real RoPertY ❑ iYmuallY As�ssed
,��T�� o��� -��A� Ly �
Ky�A � K��
\UDROR
I�1 ' 1(�9y
I p
5grehae U Camb Auditcr Caunry Date (ma+th. daY• YeaA
I/ We certify under Ne penafry of perjury that Ihe above and foregning infortnalirn is We end corteC arM that ihe applinnt is a resident of IrMiana aM
own� 4uyer of the aforemention�ymperty on date appiiradon is filed.
` / �9 .
X
/ � Full Eent address
/
�\ C_
PGSOn aNhot¢ed Dy
P4dress of authw'vcc
1Wy exewted Power o(AttmreY or Oy IC 61.1-12-0.7
person (number and 5tree( city, sfate, aM LP cnde)
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