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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou owns p r
:,_ ,. ; FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 93709 (R111609)
ti f Prewibed Ey DeP���� of Lxal Govemment Fnance
� U ���e 2^� 2009
wsrnucnoNS:
Form i�ed WRh:
To be fiied in person w 6y mail with the CountyAUditw or Counry Recorder of the county where the property is located. . ����
Filirg Dates: iJ Real P�operty: Mus( (le during the }rear /or whicA the deductlon is sought. Auditor
2) Mo6ile / Manu/actured Homes rrot a55essed as Real Property Must file dunng the fweNe (72) months
6efo2 March 31 ofeach yearthe deductron is sought GIBSO C N� ef
See reverse side for adtlitional insVUCdons arnl qualifications.
AD7�� (ownerortonvart Duyefjsee rejb'raons m reverse sitle)
Distri� Key number / legal Aesciption
-2 -O �
ed ralue d real V�PenY az N Mor�qage / Contra�
I.wrentYear Mamh�Wrten�
C
fia[ fs his / her e�ct share ol interest?
i on iemrtl s C�ifrerent than Nat of aGP� u�dirate 6ebw
Nartre ot rtqrt�agee or contrar� seller
AEtlrea of mortgagee or
Name
Hna�
�f
caunty
�
Reco�d number Page numDer
acr� 5�d
unpaid as of Is ihe app�xanl the
lepal or eQUilaGe rnmeYt
❑ Yes ❑ No
If wmetl with someone dher tlian spouse. iMiqte with whom
gnee (numDer aiM stree; rdy, sb2, am t�r caae)
ovm property in eny oNer If yrs, whac munt7/.� WR
Dr�uctian app�oved in Ne amoun
20 20
SignaGrte o( Counry Audimr
�
S�IQ PfOPfIlY Ifl G�M�OII: MM12M /�SLW
'f:2eal Pmperry Q ArmuaOyAssessed
DPall'CI' 1�`�.........
C11'C� �i�. ...�..1�.�.... .
� I O�1 �. � . .
20 � 20 � ZO
Oate (rtronth, day, yean
�
❑ No
[J _
I I We certify urWer Ihe penally of perjury that Ne above and foregoing infortnalion is We and mrtecl and Nat the applinnt is a resident of Indiana arM
owner / wntracl buyer of the aforemenboned property on date application is filed.
� e��i�, ^
� 96� n
1 K.CJCJ'e/�'�-
FWI rasid aEtlress d a�t num6er a^ A ntl �t, dy sfate, and Z1P m
C.��CJL/• •�
a mo�zee ey a�N e:e«rtea aower ornuomer or ny �c G�. �-i z-0 �
PdCress of auihoraed perso� (number aM sbee; crty, state, and ZIP totle)
�ate (rsronN.