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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
�; FOR DEDUCTION FROM ASSESSED VALUATION
_:17z? State Fonnd37es(R11/6-c@) vv
Presrn'bed by Departmerd of Local Government Fierce e, File Mark
INSTRUCTIONS:
To be Ned in person or by mail with the CountyAuditor or County Recorder of the county where the roper(y is located. Form ��
Fling Dates: 1) Real Property Must file during the year for which the deduction iy�, hQQ 1y Court Auditor
2)Mobile/Manufactured Homes not assessed as Real Property Makti%e of thee 4elve(12)months u County before March 31 of each year the deductions sought - ❑ County Recorder
See reverse side for additional instructions and qualifications. '
Applicant(owner or ctbuye/r�-,,s(�(` '�`�on ''�a�)��� �Iry-�y. }C1 92,0 JNTY AUDITOR•A ,�.J /r `� `76 rr�F/� }r��///l�A.(`I.JSQ(��JL r� o
I�� atp ' 1a'.) E'CCF1i- too. J6J-A20 Rion t Pa95 #y/
Assessed value of real property as of e I Contract Indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sale
March 1:aarentyear Mann 1,ar�iif yea date of aPP�tion gal err equBaWe await?
sue' 6-g • ❑ Yes ❑ No
If nog what Is his/her exact share of interest? f If owned with someone other than spouse,indicate with whom
If name on record is dfFetent than that of epee:ant Indicate below. Is the property in question:Annually Assessed
0 Real Property ❑AyPssessed
. / Mobile Home(IC 6-1.1-7)
M
Name of mgag a contract selle)
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and sheet,city,slate,end ZIP code)
Does app&ant own property in any other I"._ — -. What Taxing District? Has this deduction been requested on property
[�}r
�p{-� n r 2).0.11—, current� for entyea(/ ❑ Yes ❑ No
(0.. COUNTY AUDITOR
Dec Drawer 10.......
— 49 II
20 20 20 20
CardNO. .....................
.,wmrygrrttor • County Date( day
I/I/We 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 I contract buyer of the aforementioned property on date application is filed.
Signature(owner's ht name) Date(month,day,year)
resident address of oppgrant(number and street,dty, 'and3�aide)
it-s C g,6�N s7. tit/,.,CC /0.1-1 T./ Y 0 f 70 .
Person authorized by duty executed Pow of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authored person (number and sheet,dry,state,and LP code)