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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
�;; FOR DEDUCTION FROM ASSESSED VALUATION �ar-
_ jt State ibed by Department(R11 I 6-09) E g\
Ptate Ford by Department of Local Government Finance
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INSTRUCTIONS: ggrrmm..i�d
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. Fu I I I, ,()13
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought. 7L`J7 CouhtfJ d'rtnr
2) Mobile/Manufactured Homes not assessed as Real Properly Must file during the twelve(12)months
before March 31 of each year the deduction is sought. - Ce my ecorder
See reverse side for additional ins and qualifications.
0// {//rr/ / -�p . areb- os7a- 0/9 Record number Page number J !
Assessed value of real property as of Mortgage/ ., at indebtedness unpaid as of Mortgage I Contract Indebtedness unpaid as of te the applicant the sole
March 1,co.ent year March 1,current year data of a9P Q'f "n legal or equitable owner?
/ ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone Idler than spouse,Indicate with whom
If name on record is different than that of applicant,indicate below. Is th perty in question:Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or mnrraaseller i /f 0 g li _
Address of mortgagee or contract seller(nun 4 street city,state and ZIP code) _
Name of assignee or other owner or holder: age -
Dra)ver r l
Address of assignee(number and street,�:state.and ZIP code)
f\O../�G 7.... ��
Does applicant own property in any other If yes,what Card NrO• •./.� 7 -Tln been requested on property
county in lMena? ❑ Yes ❑ No .J^)•�,
❑ Yes ❑ No
.UDITOR
Deduction approved in the amount of
20 20 20 20 20 20 20
Signature of County Auditor • County Date(month,day,year)
I I We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
Slg (owner's bi name) Date(month,day,year)
er lj n.L1/ Oq(number Full resident ad applicant(number and street city,state,and ZIP code)
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Person authorized by duty execvtad Power of Attorney or by IC 61.1-12-0.7 r Date(month,day,year)
Address of authorized person (number and stoat,city,state,and ZIP code) .