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^��. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmship Year
__ � FOR DEDUCTION FROM ASSESSED VALUATION
� S�te Farm 93709IR7116-09)
S�.�. ° P2saibed M �eP�ment af Loml GovemmeM Fnance
WSTRUCTIONS: -
To 6e filed in person of by mail with the CountyAudifor or Counry Rew�der of the county wFieie the property is located. I F�1 ��q�(��'�Q
Filirg Dates: 1) Real P/operty Must file dunng fhe year for which the deduc6on is sought `�A i� L L"bY�nry Auditor
2) Mo6i/e / Manufactured Homes nof assessed as Real Ploperty: Must file dunng the tweNe (12J months
6efore March 31 of each year fhe deduction is sought C n R er
See reversa side for additional instructions and qualifications.
AppGrant( orcontrarl6uyer-see reverseside)
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7aprg D' �G �uvnher / Iegal descriDdm Rem�d numba Page numbu /
lo - 4-I -�-0 - DOI, oL�'� - O l lv (�5.5
Assessed value af mal p'operty as W Mortgage/ Contract irdebtedfress unPaid az o( Mongage / Con'vacl uMebtNness unPaid as of Is the aGPROnI the sole
Rtert�h 1. aaren[ Y� March 1. cvrtent year date of aGP�'ation legal w equitable owneR
01 DDD ❑Y� ❑No
R ro, what Is his ! her emG share af intemst? H owned wi� someone other spouse. indxate with wtwm
If name on temtl is NRerent ihan thal af appOcant, �cate bebw.
Name of mortgagee or mitraa se0er
Addres oi mort9a9ee or mntract se0..
Name of asv�ee w other owner or h
R�. a
dry, sta:e, arM LP code)
i
dimnt oSm property in any oNer tt yes. what munt�/T
Indmna? ❑ Yes
❑ No
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Is ihe pmperty in Qi
L'�kk� r�oaenv
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m N Ca�u:b /�� � Counb � Date (mae„ - —
/ We certify under the penalty of perjury that the above and foregoing infortnation is W e and oortect aM that the applinnt is a resident of I�'�ana aIW
vmer I contract buyer of the aforementioned property on date applfcation is filed.
� Sig �e (owne/s (u0 rame) Date (rnonm. daY. Y��
Fu0 ' i
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Pe�..on ai
af auCwr"ved persai
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i �o�+ br.,..� h Z N
F'ower af Aifort�ey w Oy IC 61.1-t2-0.7
her antl snee4 �l: ��. aM LP cotle)
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