Mortgage_McEllhiney , STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
L_ FOR DEDUCTION FROM ASSESSED VALUATION
'�' State Fomn4byD /1415) MI/
�- F§esatbed by Department
M Fin trne of Local Government ance �
i
INSTRUCTIONS: - e ark
To be fled in person or by mail. ,� F;rt_.
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought nn//nn 1 -
Must be filed or postmarked with the County Auditor or County Recorder of the county whem the propsU ;t�j Auditor
located on or before January 5 of the immediately succeeding calendar year. 1 a 1Q r4/ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Properly Must file with the County ditor o my
where the properly is located during the twelve(12)months before March 31 of each year 's sought
See reverse side for additional instruction and qualifications. ter
Applicant(owner or contract buyer-see restrictions on reverse side) Alt);
.ts Lq �\. M@FI hey yAU0,
Taxing District Key mimbert Record ryue})o/? so!?
at,el+. a�-k� -30�-00O .� 7a_
Assessed value of real property as of Mortgage/Conoaa indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment data,current year assessment date,current year daat W re of application 6� legal or equitattle owner?
SO DC. ❑ 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
epproperty in question:Annually Assessed
I�
�M1cal her`)' 0
nAssessed
na ile Home(IC 1.1-7)
Name of mortgagee or contract seller
J a d-1S v', \\ \\CO_CGA Cer1 . Cx_e_ctcf —
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 b t&dry,state,and Z ',/(/)//,y��1/
Does applicant own property in any If yes,what county% • ‘2.
�./i t 3quested If yes,state amount of deduction
other county Drawer NO
in Indiana? ❑Yes ❑No ❑No
A person is not entitled to this deduction unless the ndebtedness that is recorded in the courtly
recorders office(including any home equity line of c Card NO. ...... ...... ie basis for the deduction.
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 buyer of the aforementioned property on date application is fled.
fun name Date(month,day,yea
Full resident dress of app cant( bet and street city,state, nil ZIP code)
g oS . \1 cn.a., St- . a
Person authorized by duly executed Power of Attorney oriuy 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. _