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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township ( Year
FOR DEDUCTION FROM ASSESSED VALUATION
1:t state Form by Department artm/6-09) R
-�` Prescribed by Department of Loral Government Finance
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Fle Mark
INSTRUCTIONS: Forth tiled
To be filed in person or by mail with the CountyAuditor or County Recorder of the county xOemithe p Pgny is located
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought.,U i f[Q aa I County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during
the twelve 1f2)months
before March 31 of each year the deduction is sought ❑ County Recorder
6ic See reverse side for additional instructions and qualifications. Gf1�ON Cvu
Ap t(opnerQrcan buyer-sae' • nsonreve e) TYA�pITORI
��s�rv�)lV1�1�.� J number
Ta\�[X Al �M a(�13 �3r lot -t13 'OO(o IR��3 Pa951ab number
Assessed value of real property as of Mortgage/Contras indebtedness unpaid as of Mortgage I Conran indebtednes's unpaid as of Is the applicant the sole
March t,arena year March t,ga�epi year O O date of application I legal or equitable owner?N
Sxl((J7 for ❑ Yes ❑ No
If no,what is his I her exact share of interest? n awned with someone other than spase,Idl
indicate with whom
If name on record is different than that of applicant indicate below Is the property in question:Annually Assessed
u ❑Real Property ❑Annually Assessed
• (?_SL I Morita Hanle pC Cr1.1-T)
blame of mortgagee or contract seller �-.O.!/ r +'
Address of mortgagee or contract seller(number end street,r te,and ZIP code)
Name of assignee or other owner or holder of mortgage
- CC 1-)tb#), X& AJe11/
J,CRe - rT at county? - What Taxing District? Has Nis deduction been requested on property .
for anent year?
I I El Yes ❑ No
II I 3 5.11 D COUNTY AUDITOR
20 20_ 20 20_ 20 20_ 20
SN ltd I kJjc• County I Date(month,day,year)
unty Au .l
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
own-r I contract buyer of the aforementioned property on date application is filed.
•r (owner 7 name I Date(month,day,year)
- AAA ._l
ant address address of applicant(number and street.oly.slate,and ZIP cccoorddee))/ I
Person by meted al Attorney or by IC 6t.1-12-0.7 a4 -Xi I Q?&(2O Date(month,day,Year)
Address of authorized person (number and street,city,state,and ZIP code)