Mortgage_Shoemaker STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Fon i 43709(R13/10-15) 9,3on 'i r c \ 2O i 2
`-- Presorted by Department of Loral Government Finance
INSTRUCTIONS: - File Mark
To be filed in person or by mail. Form"min:
Filing Dates: 1) Real Properly 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. ❑ County Recorder
2) Mobile y Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deductionis sought
See reverse side for additional instructions and qualifications.
Applicant owneracontract rseer orlrCverse side
ILLJ.`1 1,“
J0M on - i -' - 30o-00 . g118 —o2k-t . 20 l • 1>Ter .
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indettedn unpaid as of Is the a plant the sole
assessment date,current year assessment date,current year date�p(oaton 0 C,.! legal or e owner?
�i1774W4N��11) Yes ❑ No
If no,what is his/her exact share of interest? If owned with ne other than spouse,indicate with whom
If name on record is different than that of applicant.Slate below: property in question:Annually Assessed
Real Property ❑ AnnualiyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller 1��` 1 A L E D
Address of mortgagee or contract seller(number and sheet city,state,and ZIP code) NOVq(, o
Name of assignee or other ovmer or holder of mortgage O 2C 2018
Address of assignee(number and street city,state,and ZIP code) �fj4��qq�C((��{{�� (C`�,,� 77
Does applicant own property in any If yes,what counts 11Mat Taring District? 1 Has this deductiogl: tl reque24ed��•try rsnsmteama nntt of deduction
other county ......w o 4tt_,_,
in Indiana? ❑Yes ❑No s ❑No
A person is not entitled to this deduction unless th • d indebtedness that is recorded in the county
recorder's office(including any home equity line c r O/ is the basis for the deduction.
N Drawer O... SSSJJJ
Deduction approved in the amount of. •
Card NO. ...... .1. ..
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 filed.
1Sig re(owners fu name) ////7r sc`s/ /'J QWIC
I
J`\Full r • address of applicant(number and treett � code) 1 1721
\ 101T" l 000 S 3Ct,} ,/�
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 r Date(month,day,year)
Address of authorized person (number and street thy,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.