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^'�o STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__ • FOR DEDUCTION FROM ASSESSED VALUATION ���
. suce Fam a3�os (R�i i s-0s�
�' y�. 1 Prescnbed Ey �ePartmenl of LorW Govemment Framx
File Mark
INSTT2UCTIONS: �/
To be filed in person w by mail wiN the CowfyAuditor or Counry Recorder of the tounty where ��drod eR� i���ted. Farm med wi�h:
Fi!'ug Dates: 1) Real Property: Must file dwing the year for which the deduclion is sought. � ��n Counry Auditor
2J MabiTe / Manulaclured Homes not assessed es Real Pruperty: Must h7e duringtingi���lv� Vths
before March 31 of each year fhe deducGon is sought I ❑ Counry Recordu
See reverse side (a additio�al insVUCWns arM qualifications. G IB�ON Cf1yl�TY A I i
anoGlant towneror mnerav - see � as m rcverse srlei. _ _ .
��-^1
���.,,�«�,����o,��
,����,
mortga9ee or contrad seller
of mort9a9ce w mntraa seDer (numhe� erM stree; ray, s
Name af azsiryiee or ottrel owner w
�:��
�W�OO�. !a
number Page wmbu
Di� 5�r9�.
ness unpaid as of Mw�qage I Con� udehtedness unpaid as of Is ihe eppfirant Ne sole
date of eppGntion legal a equitaWe owneR
O� nY� ❑No
o��s�.
Is ihe PmPertY in QueSGOn: Mnu:
❑ Real P.operty ❑ nrmua.,
Mob�le
� Cu3�5`�S�c�`J__"._- ---_-=__�
Dra�ti�er NO......
. �.�....... -
Dces epPlimnt ovm property in any oNer I( yes. w Ca rd \� Q. ... � 1 l a �+ Deen re9uesce7 on P�Y
munry m hM'wia?
❑ Yes ❑ No ...•.•••••••.....• � ❑ Yes ❑ No