HomeMy WebLinkAboutMortgage_Adler (3)-_^'�+ STATEMENT OF MORTGAGE OR CONTRACT INDEBTE�� 7ownship Year
FOR DEDUCTION FROM ASSESSED VALUATION
� Slate Form 43709 (R71 / 6-09)
S r Presaibed by Department of LaW Govemment F(ance
� AUG 8 2012 File Mark
wsrnucnoNs
Fortn f�eC wiN:
To 6e �led in person w by mail with the CountyAUditw or Counry Recorder of the co�nty where the pw{�erty'
Fifirg Dates: 7) Real Pmperty: Must file during the }rear lw which the tleducfion is soughL � Counry Auditor
2J MobBe / Manu/actured Homes not essessed as Real Property Must file dunng the tweHe (12) h County Reoorder
beforeMarch3lo/eachyearthedeductionissoughG GIBSONCOUNTYAUDIT
See reverse side (or additional inshuctions and qualifications.
Appfvant( raroontrarYbuyer-sy4l�estrictipQsmrererseside)
A�ssed vWire d �
A1a�U 1. amN'/m
If rio. what Ls h"a / trer ezad
-15 - Z6�{ - C�
/ Cqntract irMe6teEness unpaid as of
afrent year
If rame on �emN is Eifterent than ihat ol appfrant mdipte Oebvr.
mnUarl seDer
Addtccs of nafiga9ce w cmtrec[
Name of asiignee w oNer owner
qm properry in any oNer
�� ❑ Yes
c� ihe amount
20 _ � 20
U Counry Auditor
�7 �oo� � I �
ge / ConvaG indebtetln unpaiE as �s Ne appfrcant Ne sde
r a7P�ntim kgal w e9udade ovmeYt
❑ Yes ❑ No
meone oiher than spouse. iM'wte wfih whom
�� WoPenY m puestim: MnuaDy Asse55e0
teal PmPertY Q Mnually As�ed . . .
� �� � �2, ���,�y
and sbee{ ray, staY, aM ZIP aode)
� ��, a��,r�,
If yes. whal counry? WI
❑ No
COUNTVAUOROR
_ 20 20 _ 20
�COUnry
la-.��a�
n�
u Yes
� ❑ No
�Date (monfh, daY. Y��
I I We certify uMu the penalty of perjury that lhe above aM (oregoing infwmation is true and cortec[ arM Nat the appli�ant is a resident of IMiana and
owner I conVad buyer oi ihe aforemerrtimed property on date applicalion is filed.
auunr'ved by
�nd sLeet. ciry, state, aM Z1P mtle)
on $Z Oc�filexd
W AttaneY m bY IC Fi.t-72�.7
Aqdress ot auNor'¢ed pereon (number aid slree4
Date (rtmfi. daY. Y��)
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Date (monN. 0aY• Yaa�)