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-^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBT�� C 7ownship vear
FOR DEDUCTION FROM ASSESSED VALUATION
, Sfate Fwm 437091R11 / 6-09) .
�,.,. f Presaibed by Departmerd af Lod Govertuneiri F�nce
wsrRUCnoNS: .
JAN 5 2011 File Mark
To be filed in person or by mail witA the County Auditw w Counry Recorde� o/ tAe county where th��l��d� Fortn filed witl�:
F�Ting Dates: 1) Real Property: Must file durirg the year /or which tlie deduction is saght. �6ounry Aud"rtor
2) Mo6de / Manufectured Homes rrot assessed as Real Properry: Must file du ' Ne hvelve (12J n
befoia Maich 37 ofeach yearthe deduction is sought. GI�SON COUNTY AUDITO ❑ Counry Recorder
See reverse side for addilional insfrmctions end qualifications. �
AoaGrant (�buver- see restrirbons reir�vs�liN / 1 _
Taring ' {,f/ Key rcxnher I tlesvipUOn
��- i�3-a8-3� -a��. 5��6.oc
AsesseE vahc d real ol MoRgage / Contrau inde6tednrss unpaid as of Mortgape / Cantrar�
Mamh 1. amnt year MerM 1, artent ye�r /���. �� tlata o( app�atian
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1
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rlame or mM9a9ee «m,o-au seuer � / ^
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Pddtess W nqrtga9rs ar mntraG seDer lnumber end sbee; �y te. aM ZIP codej
Name ot assignee or othrJ axner or IwMer of irotr�aga
Pddress of ass6yiee (numherand sveet �: sbfe, end Z�P mde)
Does epplitant own poperty in any oNer It yes, what munt7/+
munry m Indana? ❑ Ye5
❑ No
unDaiO as of Is Me app0�ant Ne mle
legal a epultade owmell
❑ Yes Q" Ni
rc ownea wim someore aam. tlan sro�e. o-d'�te witl, wlim,
Ls Me property in quesGOn: MnueOy Kssessetl
n Rea� P�.wn.•-I_I....-.._W AsSessed
_ �i ���-,� �-
_ �/3 ! t� `�Gg .�
�: avir-��I �. ��,
� ior am«n yeaa
stetl on propeny
Yes ❑ No