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STATEMENT OF MORTGAGE OR CONTRACT INDEBTED..74,* T?t Co Township Year
tS, = FOR Form DEDgUCTION)FROM ASSESSED VALUATION
11, 1.� , Prescribed by Department of Local Government Finance C ISIS
INSTRUCTIONS: SEP 2 1 2015 File Mark
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction( sought
Must be filed or postmarked with the County Auditor or County Recorder of the county wl _}J ''`..'ounty Auditor
located on or before January 5of the immediately succeeding calendar year.
IBSOKI COUNTY AUDITO R � aunty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County uditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought.
See reverse side for additional instructions and qualifications.
Applies t wner or contract buyer-,e restrictions on reverse side) ...--- r
Wefh d. -1--'� Terri S lay lot
Taxi District Key number/legal descriptio Record number Page number
anion a tom-/g- ,? lo- X oo - Doll he 7q 0a5 /5 R955
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,anent year March 1,��ntyearr date of application legal or equitable owner?
1/4„,i 00 0 ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned 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
Areal Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee ntrac
Address of mortgagee or contract seller(number and street,city,state,and Zr'^Me)
Name of assignee or other owner or holder of mortgage
/ liy �K _
Address of assignee(number and street,city,state,and ZIP code) N 8
Does applicant own property in any If yes,what county? VJf �z . / S state amount of deduction
other county
in Indiana? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a uo._. � ��
� at is recorded in the county
recorder's office(including any home equity line of credit that is recorded in mt.__ :deduction.
COUNTY AUDITOR .
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor County Date(month,day,year)
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 buy:, of the aforementioned roperty on date application is filed.
Signs re •wnefs full ale) Date(month,day,year)
Full resident address of applicant(number and street,city,state,and ZIP code)
X 20 SL CO `? SOS Foo_y ".. R vbcad /N 1/ '1G (
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 / Date(month,day,year) .
Address of authorized person (number and street,city,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000. •