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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
- _. FOR DEDUCTION FROM ASSESSED VALUATION )yyy
"-,,,,._ State Form by e9 Department/6-09) I�
4- ' '9 Pnsaibed Cy 109(Ru of Loml Government Finance
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INSTRUCTIONS:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located- DE I Fz J [U I J
Filing Oates: 1) Real Property Must file during the year for which the deduction is sought 9 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 - / . ^ - • -econder
See reverse side for additional instructions and qualifications. I •i!117Hr
App I(owner or contract buyer-see resbiraoos verse side) GIBS IN (`(MINTY AUDITOR
Ta District Key number/4;a I(gal description 'Record number Page number
Bisoict d6 - a -/R - Sod - ooa. . ot83 -odc �,oi3 (odsb'
value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract cWebtedness'unpaid as of Is the applicant the sole
Mara 1,current year Math 1,currentxter date of application legal or equitable owner?
I D t,7 n I ❑ Yes El No
If no,what is his/her eat share of interest? 7 I owned with someone other than spouse,indicate icate with whew
If name on record is different than that of applicant.Indicate below Is the pmpeny in question:Annually Assessed
❑Real Property ❑Annually Assessed
• I Mobile Bane(IC 6-1.1-7)
Name of mortgagee or contract seller /J - -__ I
f6 1
Address of mortgagee or contract seller(number and street, •state,and ZIP code)
I
Name of assignee or other owner or holder of mortgage NO O/
Address�of assignee(number and street,city,state,and ZIP code) 1 :27 �y
�/� . Card NO.
1/I//// 'SSS///�/ JUr
Does applicant own property in any other If yes.what county? • What Taxing y
county in Indiana? ❑ Yes
❑ No No
COUNTY AUDITOR
•
Deduction approved in the amount ot.
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• 20 20 20 20 20 20 20
Signelu ,a County Auditor. • - - County Date(month,day,year)
I/We certify under the penalty of perjury Cthat Athe`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.
/( Sig (owrrefs fun name) Date(north.day,Mean
� I3f ` W1�.e $band t,el.state, s t IN y7� si 1
b)t A ate .
Person authorized by duly executed Power of Attor ey •or by IC 6-1.1-12-0.7 r
ut I Date(month,day,year)
Address of autlwrted person (number and street,city,state,and ZIP code)