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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS co o Year �
+ FOR DEDUCTION FROM ASSESSED VALUATION
. smca � ��os (rt„ i tws>
•�' � Presmbed by DeC��eM of Lnd Govemrt�eM Flriarce
il Ma
INSTRUCTIONS: F
To be fi7ed in person w by mai7 with the CowrtyAUdito� or Counry Recorder o� the counry where the property is bcated. �' ���
Filing Dates: 1) Real Pmperty: Must file during the year for which the deduclion is sought.
2) Mo6de /Manufactured Homes rrof assessed es Real Pruperty: Musf fiie during the hvelve (f2J months ,
before March 37 of each year Me deduction is mughG Recorder
C�IBSO C TY A DITOR
See reverse side for addrtional inshuctlons and quzlficafions.
Ap or b e m reverse si1 /)
CI�J CX ��
T Lqbict i� i Key number / I_ esaiotion Remrd numbrs Paoe numKni
�t/I��/oU�
��
11 no, whal k N5 / Irer euG share oi u
If `wne on record LS N9em11t Ufan Nal
Name ot mortgagee «wntract seller
ndd(m at rt�gre or mno-aa se�6
Name oi azsimiee or othu oxmer or h
`— DOD. � �
ss unpaid as at Mortgaga / ConSact
date of appG�t6n
c'rry, stafe, aMLPcode)
�, ePP„��� _— �OI a-, .... •
munry�
— ]�Ca��'Cl" l��•..........
���. ��-�a�.......
CACC1��• ......... •
20 _
Signawre ot w�mry Audhcr
1_
�ry
tl awneE win sarrieane
- I Z�-
Counry
anl Ne sok
iitahle,amell
Yes ❑ No
with wtwm
�Is PmPenYinGuestion:AnnuaAyAssessed
ld R� �aenv ❑ Fvmuany nssessea
ste0 m P�Y
Yes ❑ No
p- � �-
Data (rtniUh. QaY.1Ta�
20
I I We certfy u�er the penalry of perjury that the above antl foregoing infortnation is true and correa arM that the applinnt is a resident of Indiana aM
amer I contract buyer ot Ne aforementioned properry on date application is fiied.
I�d� (owne/s MI nar�e) . Date (mon�. daY.lgaA
anC sbee; aTy, state, ar�tl LPootle)
�
Address of auNwar� person (number arM sbeef, fity, sbte, aM LP cade) .