Mortgage_McKee� •
^^� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS co To Year
_ • FOR DEDUCTION FROM ASSESSED VALUATION
" � srace ram a3�os ca�i i so9)
�' „p � Presrn"6ed M Department of Lad Govemrtrent Fuarxe
INSTRUCTIONS: NOVF���12
To be fiied in erson or 6 maB wifh tAe Coun AWifor or Coun Recorder o! the cuun whe2 (he m Form Aed wrth:
P Y iv b �Y P PertY is locared. C�.
Fifirg Dates: 1) Real Property: Must file dunng fhe year for which the deduclion is soughL u Auditor
2) Mo6de /Manufaclured Homes rrot assessed as Real P/operty: Musf fife dunng the hvelve (12) monNs n p g�rd
6efaeMarch3fo(eachyearfhedeductionissoughG GIBSO COQI�TYA ITUK ef
See reverse side for addrtional instructbns arM quzlificatbns.
Mofuanl (ow,re� arcantraC buver sre restn'c0'ons m reverse s"slel .. ��, —
A�sed vahre d mal pioperty as d
Ni�n �, am�c nar
Ii rq, vTat b his l her erarl share o1 inten
�} 112RIC M R�lfd 6�iClPlli �12f1 I:N� Oi I
of morigagee «contract seller
�
ALdress ��9wmntreclselier(i
Name N assi9nea or oNU ownu or hddt
AOdms of asi9nee (number ard shee4
Does ePplimnt own praperty in any oNer
munry �n Indana? ❑ Yes
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SigruMe N Camb nWitor
nunba / le9al d�saiG�n a RecaN number Page number
l� �� 3� i�-�.aa-oa�.�V'�-a.� � a b �� 53�1
�MortAage / Contrac[ 4de6tedness unpaid az of Mortgaga I Convari cWebteMess unpaid a d Is Ne aPP�[ Ne s
Mar� 1 n�rrent yrar date of appGCatlon legal or equitaWe wrt
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No
�er end street, cX}; state. aM ZIP cada)
mcrigage
swe, and LP co0e)
I( yes. wha[ munt�? What Tari�
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spoiae,
perty In QuesGOn: Mnu
Roperty ❑ a,mua
hbW7e
__. .. _ �.�.... Men
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C_�!���0.�•'`�A��O. W.....
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counry � ...._ ..
I/ We cert'rfy under the penaliy of perjury that the above aM foregoing infortnation is true and cortea arM that the applirant is a resident of Ind'qra ard
owner I tract buyer of the aforementioned properry on date application is filed.
�rewre /W nama) n .� Date (manth. daY.1'aaA
stata,
Dare (rtronfi, dzY. Y�A
daWnraedperv'.,on (numberaMSbeeGcity.sfate,anOLPCOde)