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' STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
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S � Aesmbetl by DepaNnenl of Local Govemment Fi�nca
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wsrnucnoNS:
To be filed in person or by mad with the CourrtyAuditw o/ ff�e courrty where the property is bcated.
Fd'a�g Dafes: 1J Real Properfy: Dunng the 72 months be(me June 17 M the year the deducLon is to be eHective. MQR � 4 2009
2) Mobiie Homes assessed urMer IC 61.1-7: Be(ween January 15 and March 2 of Me year the deduction is to 6e eflective.
See 2verse side for additional instrUCtions eM qualificafions. /��/ �
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Cay �wmber I Iegal desaip6o
m 3-0 -�oo-
R real property at of Mart3� 7. anent Y�� �S
If�tiat is his / her ezact share M iriterest?
Ii name m remd is ditfaeM Nan Ihal of applicant, i�ote below:
Name of mwtgagea or canract sdler
Address of mortga9ee a aonUad seller (rrumber arW sheel. d(y. state,
Name of assgrree u oU�er owner rn hdder oF mortgage
Address oF assignee (mun6er ard sheel. cilY• sfate. and ZlP aode)
Does applicanl own property in arry olher If yes. whffi counry?
caunry in Indmna?
❑Yes ❑No
Oeduclion �pmved in Ure amaunt of:
20 � 20 20
Sigreture of Counry Audiior
>��-Da� �
uWeWedness unptid a, of March 1.
Oi /lU�./
V-ar_��
ca0e)
Whal Ta
GIBSON CO
Rem�d
is ma
spouse, indicate wilh whom.
n eq�utable owne(i
❑Yes � No
IS Ih8 PfOPB(�/ IIl QI125I1Of1:
❑ R�I Pmperty ❑ Mobile Hare QC Gt.
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I/ We cer6y under [he penalry o( perjury tha[ the above and foregoing infwmation c
Indiana and owner of the afwementimed propeAy on March 1, 20
�9ature (owners !un name)
address af applican�
sfate.
ezewted Power of Attmrey w by IC 61.7-12-.07
Pddress of auUOtaed pgson (number aM sbce7. My, slate,
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No
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