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"'� STATEMENT OF MORTGAGE OR CONTRACT INDE��� n Township Year
. FOR DEDUCTION FROM ASSESSED VALUATION
:r - .
State Fortn C3709IR71 / 6-09)
�,,,. j Presaibed by Department of Loral Govemment Firance
SEP 2 File Mark
wsrRUCnoNS: 201)
To be filed in FOfm �� ��
person a by mail with the CountyAudito� or Counry Recolder of the counry wh�e tl�e��ro9��"s located.
Fiiirg Dates: 1 J Real Property Must fJe during the year fir which Ne deCuction is sought. �County Auditnr
2) Mo6i7e / Manufactured Homes not assessed as Real PropeRy Must file dunng the twe 1 onfhs
6efaeMa�ch3loteacAyearthedeductronissought GIBSpNCOUNTY ❑ �untyRecordu
auoiroR
See reverse side fnr additional instructions and qualifications.
Asrssed relue d mal qoper;y es d Mort9a9e / Contrati irde6letlnPSS unpaW as of Mortgage / CanYa�
i1azU 1, dr�pnt ypar March 1, curtent �gp[ tlate af appGCatwn
II �w, what a ha I Mr eraU share o( interestt � If ovnn^ -"
If tume on �em�d "a tliRemst Wn Nat ol aDPIkaN. �"--' - _
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��a,,I onna- �J�,.�
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I, _�, �nq penalry of perjbly that Ne above a o e
rn.ner I mntract buyer of the aforemertboned property on ate �
�igqawre wne/s MI name)
'�/ ) � �J�
J•� e 1 J .�AA/I/4-
Fu0 resiEent edtlrrss of appfrcant (number anC stree4 rnY s7a�e, aM ZIP oo[
� loo �. S 9�-Qa�Pm.u,e ii ra�.0
Person auNO�rzed Gy Ouly executetl Power of Attaney or Cy IC 67.1-t2-0.7
Address of auttra¢e0 persan (number arM sneet �Y, state, aM ZIP code)
Caunry
as d Is ihe ePP��t Ne sde
legal or eQUitade rnmerl
❑ Yes ❑ No
i SPO�� i�icate wiM whom
k Ne property in QuesOOn: MrwaAy Pssessed
❑ Rea1 aoaenr ❑ !vm!�aly Ass�ed
iis deduUia� been re9uesteL on prtqerty
rent Year' ❑ Yes ❑ No
� �
intortnatlon is We and cortect and Nat Ne applirant is a resident of IfMiana arW
ion is filed.
7V
Date (rtmth, day, yrea�
Uate (rtionN. tlal: yea�