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//�y STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County I Township - Year
/3 Yn ' FOR DEDUCTION FROM ASSESSED VALUATION FILED
.H,-,\,.,-,• „ Preresaibed by Department/11-08)
of Local Government Finance I
INSTRUCTIONS: I Filq 6la(� 2014
To be filed in person or by mail with the County Auditor of the county where the property is located. .1Fi�V �j Y
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)months before M 31,of e
the deduction is sought. JG ._
See reverse side for additional instructions and qualifications. GIBS 0 N COUNTY AUDITOR
Applicant(owner or contract bluer-see restrictions on reverse side)
Taxirg,,D,ism one K y number I legal description �y �� Record number Page rum er
W is •
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Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current year • date of application legal or equitable owner?
f'a59 q5o -i ❑Yes ❑ No
If no,what is his/her exact share of interest? If wined with someone other than spouse;indicate with whom
If name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
I Mobile Home(IC 6-1.1-7)
Name mortgagee-or contract seller r D
Address of mortgagee or 1 tract`,sryellerw(nuumbberr` and street city.state,and cod
L R �t�.+ LSD f • S (2es4S1.. x/14 �O l 4 1
Name of assignee or other owner or holder of mortgage I
Address of assignee(number and street,city.state,and ZIP code)
Does applicant own property in any er If yes.what county? What Taxing District? Has this deduction been requested on perry
county in Indiana? for current year?
❑ Yes No I ❑ Yes No
COUNTY AUDITOR I
Deduction approved in the amount of:
20 20 20 20 20 I 20 20
Signature of County Auditor County I I 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/contract buyer of the aforementioned property on date application is filed.
Signature(owner's furl name) Date(month,day.year)
'XA k 2., l - a, 13
Full resident a dress ojapplicant(number a d Mmes ty,state,and ZIP coda) ��
—(R C a `5 G� . 3YAY�CQ�,D.t (nc-t-g
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 I Date(month,day.year)
Address of authorized person (number and street,city,state,and ZIP code)
I