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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form by Department(R11/S-O9) 'LED
Presaibetl by DepaNeent of Lod Government Finance
INSTRUCTIONS: F
To be fled in person or by mail with the Cowry Auditor or County Recorder of the county where the property is located H t�li 2013
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought TL"�JI County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months _
before March 31 of each year the deduction is sought. , I ntya�-
I..,. —:�rnwt. on
See reverse side for additional instructions and qualifications. GIRCON COUNTY AUDITOR
Appfcanr .r or contact buyer/ee restriclods on re side
T.: •`r , / Key her/ desaip i Record number P e number
/ -/ , ,_663. 79.5-o 7 '173 23/a
Assessed value of real p .y as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
March 1,arrant year March 1,current year date of application 90 legal or equitable crones?
/ MO ❑ Yes El No
If no,what's his/her exact share of interest? If owned with someone other than sparse.indicate with whom
If name on record is different than that of applicant,Indicate below. Is property in question:Annually Assessed
Real Property ❑Annually A
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller -2, .
Address of mortgagee or contract seller(numbet/S6-2,
r / /and sheet,city.state.and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,stare,end ZIP code)
Dees applicant own property in any other If yes,what county? - What Taxing District? Has this deduction been requested on property
county in Indiana? ❑ Yes ❑ No for current yea? ❑ Yes ❑ No
COUI MAR(�-E57 JE eghky
Deduction approved In the aunt of:
20 20 20 20 MELArc.�lC /t' 20
Signature of County Auditor !7 f 7 tar)
I/We certify under the penalty of perjury that the above and foregoing i 13 .023 nt of Indiana and
owner I contract buyer of the_ mentioned property on date appliicani
signature(owner's full name , I Date(nom,day,year) .. - .qp
Y Aller lA.1
of applicant umber street.city,,Ate,and code)
P /20 (cn7424/ lr i'Givc =/v . iko?r]
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code) .