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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE tCMinty hip Year
"� FOR DEDUCTION FROM ASSESSED VALUATION p
gate Form g70g(R12/&tor) gJ
/ Presaibed by Department ol Loral Government Annie
INSTRUCTIONS: SEP 8 20f'f
/
Mark
To be filed in person or by mail Fenn bled Met
Filing Dates: 1) Real Poperty Must be completed and dated In the calendar year for which the deduction is sosht
Must be fled or postmarked with the CountyAudta or County Recorder of Me county where? -pm.._� a� a County Auditor
located on or before January 5 of the immediately succeeding calendar year. el"•r County Recorder
2) Mobile/Manufactured Homes not assessed as Peal Property Must file with the Co w I.....,....fpJ.y. .,1 U ( O R
where the property is located during the twelve(12)months before March 31 of each pet, -oeoucbon•sought
See reverse side for adthaonat instructions and qualifications.
Ada `�P ,w�1y{pI'm(.Q,n�en(nee \ \ � • `- \letse k
Tadhg Dis d cc-see
'^'ibe'�V�fi�) Record number Page number
(10UINb�IC-COW P -Ii-- IQ-104 OD. 303-bOh c01`! 379
Xs:Assessed said d teal property as d ` gages indebtedness urpald is of Matgage I Corded irdeaedness urpa4 as of I�a e sae
1.rime pleat r (\ d(l Mxdt 1,
I \: ),7000' cW . A Yes ❑ No
If no,what Is ctrl her eaaa-hare d tamest? a moved wan someone other spouse,Indicate with wham
II name on record is deerem drat that of appnart Indicate below. 1s the property In Weston:Nay.::y Assessed
❑Real Property ❑ Annually ua Assessed
(IC&1.1-7)
Name of mortgagee or cr tnd setter
Aoaess of mortgagee or contract seller(=oar end steel City,stet,and ZIP code)
Name d assignee or OW owner or Iplder d
(jA A. NI 6A-ifl r\0-A PMI—fIl,L
Address d averse(numbera steel,any.dye,and ZIP code&
c 1 own pe �I y 'o ? 1vm 12 i Al �7 70
Does own IaWa1Y n any u. es. rnmty7 k i t Taxing- District? Has 1 eras dedrrdan been reWesea n yes,sate errant of deardiM
1�
In
other Indiana? ❑Yes asanyea? ❑Yes El No
A person is not entitled to this deduction untess the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any lame equity line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Deduct=approved In the amour ore.
20 20 20 20 20 20 20
Sipna al County Auditor Carty Dale(=nth,day.lean
I I We certify wider the penalty of perjury that the above and foregoing information is true and cared and that the ap$cant is a resident of Indiana and
owner I contrail buyer of the aforementioned property on date application is filed.
S- ..(owners AS name) Oats(month.day,yeef
�..�_. I .:! , . /�irr ,,'1_.:, _ / . q U-
Person Whetter'by day ersated Pceer or Atdmey or by IC 8.1.1.124).7 Date(mdmb.day,yen)
Address of authorized person (number end street thy,state,end 2/Pcode)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 510,000.