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rs STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Dy ' Township Year
' FOR DEDUCTION FROM ASSESSED VALUATION 4 If.�:- Sias Farm d37l9(R13/tats) ' ®$
Presaibed by Department of Local Government Finance
INSTRUCTIONS 0 Zp+ ,6 File Mark
To be fled in person or by mall. 1. Form filed with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is soug
Must be filed or post marked with the CountyAudrtor or County Recorder of the ... is•- _ -yperty is minty Auditor
located on or before January 5 of the immediately succeeding calendar year. IN i .�";�let R
2) Mobile/Manufactured Homes not assessed as Real Properly.Must life with the eked.c.,. �r+olma c u ty ❑ County Recorder
where the property is located during the twelve(12)months before Mardi t •• -. •--deduction is sought
See reverse side for anfional instructions and qualifications.
Applicant In or conitr up7 -ry KiwRon ry ) a •
�T ' DAistrict �/ Key /legal Wn Record number Page number
//�[�//'M`'`/'O �- /a-07-�c�-oo/. 7&o-OD i6 y8i7
J`value dm!property as of Mortgage/Contract Indebtedness unpaid as of • Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessrnent date,current year assessment date,current year date of application legal or equitable owner?
❑ Yes ❑ No
If n,,what is his I her exact share of interest? If owned with someone other than spnicn,indicate with whom •
I
If name on record is different than that of applicant indicate below: Is the property In question:Annually Assessed
❑ Real Property ❑ Armuaey Assessed
/� /y�
Mobile Home(IC 6-1.1-7)
Nacre of mortgagee or contact seller lL OWI 1��.srl - n _ _ -
Address of mortgagee or antral seller(number and•ijit raq,state,and ZIP code) STELA /3/C A,(JI L —
•
Name of assignee or other owner or holder of mortgage ' J014 AP J J 2 —
Address of assignee(number and street ally,stofe,and ZIP code) 1(0 -46)-1 —
Does applicant own pi',way In any t yes,what county? - What Taxing District? Has this di
other in Indiana? ❑Yes ❑No aarent�? ❑Yes 0 N I
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county '
recorders office(inducting any home equity fine of aedt that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR "
Deduction approved in the amount of
•
20 20 20 20 20 20 20
Sgnature d Atrtidor Courtly /j'Jf(J,1 (� Dale(m a day,year) ._ (
I We certify under the penalty of perjury that the above and foregoing information is true and coned and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
' �['6 tuff_ name Data(month,day,year)
• ant address of applicant number and street city,state,and LZfP code)
8/6 E o&k Sl, P�1ti,:,,v1)v fin/ 4/76 70
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 steel tidy,state,and ZIP coda)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.