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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun sh
+ FOR DEDUCTION FROM ASSESSED VALUATION
.• SIa[e Fwm <3709 (R77 / 6-09) .
�' �.. j Presaihetl hY DeG�eM of Local Govemment Frwice
� File �E 2 g Z��2
INSTRUCTIONS:
To 6e filed in person a by maD with the CountyAudiror orCounry Recader of the county where the pmpeRy is located. F� ��w�
Filiig Dates: i) Real Pmperty: Must fi!e during the yrear lor which the deduction is soughL � Counry i
2J Mo6ile / Manulacturcd Homes not assessed as Real Pioperty: Must file dunng the fweNe (12J months IB�d (Qq�e�'
before Ma/ch 31 of each year the deduction is sought. � TOR
See reverse side for additiona/ insfrucGOns and qualifrrations.
Mpfr.�pt,jowrrerpyconhaa buyer' sef 2sfrictiorts m leye{sa sidejrJ / - .
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1( n0, w�al is Itis I Iws ex2� sti2rt Oi N1eresC!
It nanre m rcmd's QRfuuit Nan ihat o( app5ranl, uiCitate below.
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Name of mort8a9ee w mntraG seller 6/y�
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Address of mort9agee a contran seller (num6u and straet, cip; state,'aM i
Name a1 assignee w other owner or hdder of rtprtgage
AEdress of assignee (numbri aM stree4 �1: s+a1e, aM LP code)
Dces eQplicant wm yopeNy in any oNer tt yes, what county7
caunrymindiana? i-'I ..__ I—I .._
iction approvad 4� tl�e amount af.
20 20 24
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Wh2t Tadlg District7
AUOROR
I numbrl
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Y� u No
Is C�e OroP�Y in question: AnnuallYASSeSN
❑ Real ProPenY ❑ ?!?�!��Y �
Has Iha deduction Oeen requesteG on propem/
for w'rent yeaR n Yas ❑ No
20_ 20= - —' "^ - —I._20__
�,,,ry you��, 7C�F2�� K _
/n:. �2�4s�vt -
untler ihe penatty of perjury that Ne above and foregoing intortnation is we and a
act buyer of the aforementioned property on date application is filed. %;'] „ l�i� •) � _
fnm��i . i vl J 7tT
Person autho�aed by dWy execvted Power of Atmmey or by IC
Address of authomed per:m (num6er arM stree4 �: sfete, a
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Date (rtanlh. daY• Y�A
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