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'°'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
_ • FOR DEDUCTION FROM ASSESSED VALUATION
srace rorm aa�os (a,i i s-os�
S � Presrnbed M �e0artmern ot Local Govemment Frunre
INSTRUC710NS:
To be filed in person of 6y mad with the CourrtyAUditor o� Counry Recorder o/ the county whera the property is located.
Filirg Dates: 1J Real PmpeRy: Must file durtrg the year Por which the deduclion is sought
2) Mo6Ae / Manu(adured Homes rrot assessed as Real Property Musf fiie durrng the nvelve (72J months
be£ora March 37 0l each year the deduclion is saght.
See reverse side for additional insWCUons and qual'firptions.
Appfzaqt f�.ner or crntrap( buyltt see re�t6ns m rerersre si�e) . �f ..
I� mimEer/legald�
6-1 '
����o� ��e,
1'�
ro, what is hLS / Mr elmct share oi Inferest?
name on recortl is drtterent lhan ihat ot aPP��t ��� belaw.
Name at mortgagee «mntrad seAer
Addrea of rturtgagee or mntrad se�er (nun6erand sbaet, cdy yam. pl�'il��
Name of assignee or oiher awner w hdder W rtprtgage
PGAress of assignee (number and shee4 Gb, slate, eM LP code) ..
�oesePWinntown Wo7�rtYinanydno. � �� /�i'� � //1(_,/1L� �
munryinlnd'�ana? � ��l7
❑ Yes
A,tJ�u� O
De�ucEan approued "m Va artwunt of. ��j T b IU$ �� �M (
/ V � � � � �
?
���q{� ryAUditor
III"�
Cdtfiry Reoorder
COUNTY AUDITOR
i`debtedness �mpaid as o( I Is �he aDDfuznt the sde
legal or equitahie o-xnrYl
❑ Yes ❑ No
han sPO�se, iMimfe wiM whom
Is the PropeM1y in 9��: �nually hssessed
�RealProPenY ❑!�!?��Y�.._
P�rtY
❑ No
2�_ 2�_ /�5`��� _ �p_ 20_
Sig�aNre of CotmN AuOitw Counry Date (rtrmfh. daY Ypa�
I/ We certify unAer Ne penalty of perjury that Ihe above and foregoing infortnation is W e and corteG and that the applican[ is a resident of Indiana and
owner I wntraci buyer of ihe aforementioned property on date appficalion is filed.
$IORl11YC iONTB�6 il� 113(lIBI �_ i� � 1� MIn (rmnlA Aav weA
Pu�.,on authoraed by dWy ezecu;ed Aower of Attnrt�ey w by IC 61.7-12-0.7
Address of autharrzetl person (num0er and sbee4 �+N. stlte. and LP cade)