Mortgage_Lance"�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou � Township Year
,__ ., FOR DEDUCTION FROM ASSESSED VALUATION � K1
.. , Slate Fartn 43709 (R71 / 609) /j //�� 1 \
�' 1 Presaibed M DeD��M of local Govemmenl Flrence 1✓ �/ :'
� � File Mark
INSTRUCTIONS:
To be filed in person w 6y mail with the CounyAUditor or Counry Recolder o/ fhe oounty where fhe property is bcated: �.
Fifmg Dates: 1) Real Property: Must file d�mg the year for which fhe deducLOn is so'yhL � Cow Auditor
2) Mo6Re /Manufactured Homes rrot assessed as Real Property: Must file dunrg the hveNe (12J rtronths-
bePore March 37 of each year the deduction is sayht. Recorder
See reverse side 7or addrtronal instructions and qualifications. GIBSO
Applip (owne�uoontrartbuyer-seereslnc0onsmre e)
�
Tad(g istriri Key man �legal Oesaiption Remrd number Page number /
6-i/_ 3i-,�oo-ooy. as8.00� l011� y1v5
eYad share of inteiest?
tl name m recad'a Edferent ihan Nat of app6ranl, trditate hebrr.
Name at rtnrtqagee or contrad
Add2a oi nnrcgagee w contrari
ovmer or holder af mortpage
Mdress ofps9gnge (number aM streef, dry;
Dces epplipnt ovm pmperry in any oNer
munrymin0¢na? n ..__
of
20 I 20
a �f avrtred with somearre
antl ZIP cotle)
i��� � unM
COUI
20 20
�
�� �
Yes ❑ No
indx�ate Wih whom
is Me P�7QrtY in VuesGOn: MnuaM Assesscd
��i�aeNr 0,�,�ya�a
_��;���2��.w ^
WhatTabi �(\.�� rtoperty
Y ...... � No
�C1\\'Cl' \�.....
\UDROA L, � � 5. . . .
C8C(1 �� . ..............
Counry
20_ �� 20_ � 20
Date (rtanlh. d2Y. Y��/
I/ We cerlify under Ne penalty of perjury that the above arxl foregoing infortnatio� is we and correa and Nat the applipnt is a resident of Indiana aiM
owner I contracl buyer of �he afwemerrtioned property on date appliption is fileG.
�Y
Md2ss
person (num0er arM slree4 pN. state,
0
Date (rtanN. tlay.
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