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s � STATEMENT OF MORTGAGE OR CONTRACT INDi Township Year
'7- FOR DEDUCTION FROM ASSESSED VALUATION .State
Presai ed by0D Department me 15) NOV 3 . '016
Presrnbed by Departrnent of Local Government Finance
INSTRUCTIONS: File Mark
To be filed m person or by mart. 4 smiE Form bled with
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which th-I'1.luau.`•
Must be fled or postmarked with the County Auditor or County Recor�i8$ld:.r,t+!`,!,• prolpTertrty is. a County Auditor-
located on or before January 5 of the immediately succeeding calendar year. CI 2) Mabee/Manufactured Homes not assessed as Real Property.Must file will the County Auditor of the county CO11n 'Recorder
where the property is located during the tweive(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications. •
Applicant(owner'or buyer-see restrictions on raversehde) - ...dial .
Taxing Disi nit. Key number r legaf'desaipt n Record number Page number
hi a!0-Oh. -/S-d00 oco Jt 7 O/ 7 2O/4 - /3r7
Assessed value o properly mot Mortgage I Contract indebtedness unpaid as of • Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
asa¢sarwaddate.caenerd year
assessment date,aarerd year dale of application legal or equitable owner?
/53i/3a ❑ Yes ❑ No
If to,what is his/her exact share of interest? If owned with someone other than swum.,indicate with whom
If name an record is afferent than that of applicant,indicate below: Is the properly N question:Annually Assessed
ra Real Property ❑ MoH 6-1.1-7)
Nam of morrgee or rot setter
O„r z
Address of mortgagee or correct 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,al);state,and ZIP code) •
(/�)/
Does applicant own property in any If yes,what county? what Taxing District? w Drawer t\'
O..20/Ce Inchon
other county
in bndlana? ❑Yes ❑No • ••••••.. '
A person is not entitled to this deduction unless the person has a balance on the pens he county
recorders office(including any home equfy fine of credit that is recorded in the cotta Card NO 43 g-q--
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 l contract buyer of the aforementioned property on date application is fled.
rani oawerfull i`(131��y�)
Full end address of applicant(number and street,city,state,and ZIP code)
NI b`�6-- F— 5or3 o �r�,c_ sco , `ft76-(q
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 dty,sate,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.