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"^� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__ FOR DEDUCTION FROM ASSESSED VALUATION �
• State Farm 43709 (R11 / 6-09)
, � PresaiCed by Departmenl 01 Lad Govemmenl Frerca
ile M
INSTRUCTIONS:
To 6e filed in person a by mail with Ihe CountyAuditor w Counry Reoorder o) the county whe2 the ploperty is located. F� � .
Fiing Dates: 7) Real Pmperty: Must file durirg the year (or which the derlucfion is wught. p C�O �� quditor
2) Mo6de / Manufactu2d Homes rrot assessed as Real Property: Must file dunng fhe hveAre (12J months
befo�a Maich 37 01 each year the deduction is sought ❑ Counry Recorder
See /eversa side for additanal instructions and qualifications. /(� �'
A° �`� `or�ab�,ye`J���� ��`p`�es�e� GIBSON C UNTY UDITOR
iJla��nn H'l\1 I/i�nnnn.n
As�ssed vaM1e U 2ai po7�Y as W
MaUi 1, mreN /ear
11 ro. Wh2� IS hISI IM! BidCI 5h8f8 O( YItPlP_517
�— � — c—
r/ Contraa Udrbtednass unpaid as of Mon
n�rtentyear tlata
It nartre on �amtl is dAluenl Nan ihat of aDpOCam, u�dipta Delow
or rnntract
snee4 �+N. sta.e.
oNC ownu w haiAer M mort�a9e
Mdress of assignee (number entl atreeG riry, slate, aM Z/P ootle)
Does appiitanl am propvty in 6rry dhb I! yes. what
miNVinlMCrw9__�' ^ .
rc aw�d wiN somerne otnat
for
number Page numCu
IO.S ,�
as of Is ihe appfrcant Me sole
legal w equttzde ovmeR
❑ Yes ❑ No
with vAom
� ProPertY in Questiorr. MnuaM AssesseE
Real Property ❑ MnuallyAsse55ed
steE m p�opetty
Yes ❑ No
D� 11',C1 \iO..��,,.�C COUNTYAUDITOR
4f:�:�.........
ca�-� ��o. ...�435 zo_ �_ �_ zo_
D�J . . . � . . . . . . . . . cW�ry oa� (,,,�r�. dar. r�d
N � q6, 3m. —
1/ We certify under ihe penalry of perjury Mat Ihe above and (oregoing infortnation is We and corret3 arM that the applipnt is a re5ident of IrWiana aM
owner / wntract buyer af the aforementioned property on date application is fiied.
IriamrB.lo�me/s fiN neme) � 1 1 �� (�^�^�• �Y. Yea�
appGCant(number
fuy exeated Power NAttaney w by IC 61
person (numberarM sbee; ciry, s!ale. an0: