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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION y�
jState Prescribed by De aztt t 6-09) F fF-{
---"' Presmbed by Depanmerd of Local Government Furore /
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INSTRUCTIONS: 0 ¢ tpatl�•i To be filed in person or by mad with the County Auditor or County Recorder of the county where the property is located. C T D [U Iy
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought ❑ County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months)/ l-1
year 221 • mty Recorder
before March 31 of each r the deduction is sought � X}yt.
See reverse side tor additional instructions and qualifications. G)BSON COUNTY AUnfTpa
)(owner ormmary 4 see restrictions on reverse side) C 1
Ta,b!x�� - �( / `f �'to number al- Oa $e- 0l '/ -Do 3, 015- 0 /x( ?co K Page number (o
AAsessedd value teal property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the appEcant the sole
Mand11,anent year March 1,current year date of ap/pparreto/n legal or equitable owner?
If no,what is his I her exact share of interest? If owned with someone eoott>er4.an spouse,bdicate with whom ❑ Yes ❑ No
If name on record is different than that of applicant indicate below. Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
. Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and street,coy,stale.and ZIP code)
Name of assignee or other owner or holder of mortgage -_ _
Address of assignee(number and sheet city:state P castle)
. PT M D 114 1 1 ter ' 1 . 7 9 5 A c . Drawer NO.....•0/cl
Does applicant own property in any other If yes,what county? - I What Taring District? •• ... _
county in Indiana? ❑ Yes ❑ No
Card 1NO. .. Cco
COUNTY AUDITOR _ ••• _
Deduction approved in the amount of -
20 20 20 20 20 20 20
Sig/nali�ze.o"ff County Ay-Atoorr County Date(month,day,year)
I I We certify under the penalty of perjury above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner I contact buyer of the aforemeentioned property on date application is filed.
I/Signature(on A nameeAxL e i\/ Date(month,day,year)
x/F 3f�lot G 773 (number/� z.Jtely n Tw code) 'l7h io
Person authorized by duly exececutedd Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and sweet city.state,and ZIP code) .
A