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°'* STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
_ � FOR DEDUCTION FROM ASSESSED VALUATION
• Slata Fwm 43709 (R71 / 609)
� � PresatteE M DeP�ertl of Lacal GovemmeM Fi`arce
INSTRUCTIONS: tt�
To be fi(ed in person a 6y mad with the CoumyAUddor or Counry Recader of the counry where the properry is located. ��� � L� � 2
Fililg Dates: 1) Real Pmperty- Must fiie durirg the year (o� which the deduc6on is sought. � Counry Auditor
2J Mo6�7e /Manufactured Homes lrot assessed as Real Property: Must lile duAng the hxeNe (72) months �
before March 31 of each year the dedudion is sought. - �d�
See reverse side kr additional instructions and qualifications.
M wnerar mntraC buyer' �.M rervse side)
Tax'ug . Key ruandFi / legal dtSaiP� Reco�d num0u Page numbrl
-� _oa.-loo-ooa-.ao3_oa,5 �or �!o
Assessed rahie of real p�operty es of Mor�qage / Contracl 4Nehtedness unpaid as o( Morigageo /p �Conbact indehtedness unpad az of Ls ihe ePP�t the sale
Mad� 7. aamrt year Maitl� 1. wmnt ye�. �� �` 8�J �"n n n cJ � n�YP�.se �
i�
If m, what Is his / her araU share of interrst?
Itrwne at femld'a
mortgagea or contract seller
of mart9agee w mntraa seDer
Name oi azsignee w other owner w
sneeC �l: slate.
� � _
apvlitant ovm praperty in eny olhu
y m Ind"ana? ❑ Yes
❑ No
c�on appioved in tlie artrounl oE
20_ 2�_
d Caiu:b Audrtor
I/ We certfy under the penalty o�erjury that
owner I contract buyer of the atoremerrtioned
iRa�ue (ovmefs hill �me) _
ciry, state, aM LP code)
— 1 �
' Yes. whal
H
0 �
5P01152.
Is the vroPeN' in questim: MnuaMASSesseO
I�R�eal ProPertY ❑ %vmuallY As�sed
Tad� Datricl7 Has ih�s deduGion Deen reQUesteE on proD�Y
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COUNTYAUDROR '— � f ' �' `
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a201 °�.
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he ove aM foregoing infortnation is W e and correra arm tnat the applirant is a resident of Indiana ard
� rry on date applicaqon is filed.
' o-ate Imonm. day, yea�
dty, state, a� LP
auNa'¢Ed Gerson (numberaM saeeC �: state, arM LP cade)
Date (rtqnM.