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• STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
,�'� fi+rinty Township Year
rt "i' FOR DEDUCTION FROM ASSESSED VALUATION
Prescribed by Department of Local Government Finance I it
INSTRUCTIONS: File Mark
ro be filed in person or by mad. JUL 19 201r1e :
Firm Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is ❑ County Auditor ,
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufachned Homes not assessed as Real Property.Must hie wish the CamtyAuditor Q County Recorder
where the property is located during the twelve(12)months before March 31 of each yeaaleggiStOtittMERtitAU J I I OH
See reverse side for additional instructions and qualifications. •
Irinor contract buyer-see on reverse side) 14-43-t‘
era-A,Ltai
ict Key number/legal description Record number Page number
,„,_ ,.� . 4 _/A.- 08 -o203 _ooI . 1a7 -01•.8 Ao17. A- (033
ue of real properly as of Mortgage/Contract indebtedness unpaid as of • Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment data current year assessment daa,cement year data of application legal or equtabtn owner?
/Y gll DD D El Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other than spouse.indicate with whom •
If name on moved is different than that of applicant indicate below: Is rthee property in question:Annually Assessed
YA'meal Property ❑ As• ialiy Assessed
/� J Agee Home(1C 6-1.1-7)
named mortgagee o contract cuter p 7.. C I.4 - —
Address of mortgagee or contract seller(number and sheet,city,state,and ZIP code) 4'4/7r 5 0. —
—
Name of assignee or other owner or holder of mortgage ' K O / /�/
. Drawer NO -• —
Address of assignee(number and sheet thy state,and ZIP code) •
�O({//� cr--�
Does applicant own property a any If yes,what county? What Taxdrg District? Has this Card N O• - . 3�J
� ❑ t� ? Yes ❑No amnt _ _
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
recorder's office(including any home equal,/fine of credit that is recorded in the county recorder's office)that is the bass for the deduction.
COUNTY AUDITOR ' -
Dedndion approved in the amount of
20 20 20 20 20 20_ 20
-Signature of County County Date(month,day,year) • ---
I 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 fled.
Signature( errs tuff ) 1 ` Data(month,day,year)
resident address d ap (number and street,city,state,and ZIP code)
60� `Kehne`J'"`i aDr. 1?rit\ceton 1N 97t070
Person authorized by duly e>a Pourer of Attorney or by IC 6-1.1-12-07 Date(month,day,year)
Address of authorized person (number and street say,state,and ZIP cede)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 310,000.
. . - filitite Ian