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O� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun shi " r
__ .• FOR DEDUCTION FROM ASSESSED VALUATION
' � • Sfate Farm 43709 (R71 / 6-09)
�' y,� , P�esmbed by DeOM��rt af Laal Govemmefk Firunce
wsrRUCnonrs: �B�` 2013
To 6e filed in ersan w b ma� with the Co Auditor o� Coun Rewrder of fhe coun where the F� �� ��
P v �Y b �Y G�PeNY is located. .
F�Tirg Dates: 1) Real Property: Must file dunrg the year for which the deducfion is saught ��
2) Mo6de / Manu(aGumd Hortres irot assessed as Real Property. Must file dunng the hxefve (12) months
6efoie March 31 o(each yearthe deduction is sought. Ci18S N U f2
See reverse side for adCifional instrucGons arnf qualficaGvns. � _
0
u'/itif.c / w - / v - -
Asessed ralue of real propMy as ot Mwtqage / Contra�
M2iWl.axrartyear Mart3�1 artent
n na w�i � n� i ne� � si,�a or �+��+?
It name m remrd a Nfterent Nan
Name ot mortga9ee ar antracl sNler
rtrortgagee or mntraC
or other ownu w Fwlder of mortgage
stdfe. arrdLPwde)
AEtlress of asagnee (nu+nber aM slree4 �'%b, s1E:e, and LP Code)
Dces applimnt own praperty in any
munry in indara? I-1 .._.
20
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epp�wed'a� Me artrount of.
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20 _
a o(
NTat Taang Oistr
COUNTYAUDROR
20_ 2(
Caunry
(/ aeco�d numba
i� /3
mdebtedness unpxid as W
Y� u No
SPOIISf.
k praperry in queSCOn: Mnually Pssessed
Real P(oPenY Q M^uaihl Asse�ed
-rn� y���e DNKr
P�, y
a�i.�- � � 3
Date
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I/ We cerbfy under ihe penalry of perjury that Ne above arM foregoing infortnation is We and cortect ar�d that the applirant is a resident of Indgna aM
owner I wn4acl buyer of Ne aforementioned property on date applipdon is filed.
ma;�e (owne�S h� rmme) .. Daie (month� daY. Yea�)
an7 streef,
Dy duty �ecu:ed Pwer ol Attmiey ar
Pddress of auCiof'vEG per..wi (�umDerantl sbee4 tlty. sbte,
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