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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEB Township Year
_. FOR DEDUCTION FROM ASSESSED VALUATION ���
�• Slate Fortn 43709 (R11 / 609)
�` Presoibed by DepartmeN of LaW Govemmenl Firexe
wsrRUCnoNS: JUL 12 2011 File Mark
To 6e filed in person or by mail witA the CounryAuditor or Counry Recorder o! the counry wAem the,pro ted. F� �� ��
Fr�ing Dates: 7) Real Property: Must !le dunrg the year (or which lhe deduction is sought C.'�1. ��� q���
2) Mo6ile / Manufactured Homes rrot assessed as Real Pmperty Alust file dunng the (welve ( s
6efore March 37 0! each year the deduction is sought ❑ Cou�b Remrder
See reverse side Ior addlUOnal in5frucGOns and quelilcations.
GIBSON COUNTY AUDITOR
I�WPGCa�n(owne�or traCbuyer- mre�nzrsesid ). _ .-. �T'
m
Name af rtnrtga9ee or contract seller
Name ot a" �
AEdress of as!
Ooes appli
oounry in Ir.
��� �
2� _
Signature of
I / We cerl
owner / a
���(o�
ull reytleN a
�
Pe1wn aulMr
Key rwmber /
Mwloage / Conbaa
Mart�h t, airrem yc
-36 ' 3�o-ooi .� �a
��p[etlness unpaid az ot MMgage I Cantracl u
ht
appGCarn, uMipte bebw
53
mn�bv erd stree[ rily. sb1e. aM ZIP mU
u oi mortgage
�Y. state. aM Z/P wtle) .. _
prawcr ti� • •°•���•�..........
CardNO. ��5�!�...�..
-� iti4,�°'.
nder ihe penaltj� of perjury Nat t�je above arW fc
c[ buyer of ihe aforementioned Droperty rn date
fiAname) A
o( appliranT(wm6e� antl sbeef, ff(y, Stdt¢, entl ZIP mtle)
W, �zff g�,?t j2, c�n �4 k
dWy ezewted Power o(Attorney w by IC G7.1-12-0.7
person (num6eranOStree;ary,SYdfa,andLPmde)
What Tari�g Distrirl?
�
RecoN rwm� I Pagen��)p�pr�
� U ��
unpaid as al Is Ne eppi'xant Me sole
kgal w cpuilade owneR
n Yes ❑ No
Is IM V�PenY in qurstion: MnuaOy Assessed
❑ Real ProPe�Y ❑ ���Y�
Moax w«� nc s
Has Nis Cetlu�Yim Eeen requesteE m property
tor W�n W� r-i __ r� .
� � �
� � � �)��'q('�J ri� U�—/ CX'
informalion is true and corte�Y arW ihat ihe applinnt is a resident of IrMiana aM
ion is filed.
�,/7�� 9
oa� c�m. e�Y,�n