HomeMy WebLinkAboutMortgage_Leible'^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES� un o ship Year
; FOR DEDUCTION FROM ASSESSED VALUATION
Sfate Fortn 43709 (R11 / 6-09)
�' ,.,. 1 Presaibetl Cy �epanmem of Loml Goremrtrent Fnance
srnucnoNS:
JAN 2 3 2012F�1e Mark
o be filed in person w 6y mail with the CountyAudhor or Counry Recorde� o/ fhe county where the pioperty is�]oiated- F� �� ��
Fding Dates: 7) Real Pmperry: Must file dunng fhe year for which the deduction is sought. � County Auditor
2J Mobile / Manufactured Homes rat assessed as Real Property: Must fi7e dunng the hvelve (12) months
before March 37 ofeach yearthe deduction is sought. GIBSON COUNTY D RCounry Recorder
See reverse side tor addifbnal instruclnons and qualifications.
Appf�ny{pwner ar wnhact buYer- see resbicnon3pq4eyerse sid4) A
� � Key nwnGel / legal tlrsaiptian Remd^y mbv Page rwmCer
-/ S � /D / - ct3 / / - O � -F� / �
U real as of Mwtgage / Contract iiMebiedrress unpaid as ot Morigage I Contract inEeMedness unpaid as of Is Me appfirarrt Me sole
yrar Mamh 1, curtent year tlate of apptintion legal w equita6le pmeR
❑ Yes ❑ No
�/ her e�act share of interest? tl owned wiN somearie dher Ihan spouse. iMirate wNh wlwm
If name m
Name ot wtgagee w contract 5eller
CG/
Aildmss of rmrtqapce or mntraa se0
or aher owner
strcef, �ly, slale,
Dces applicam ovm propesty in any aner
counry in IMiana? ❑ Yes
Deduaon apyoved in Ne
20 _
Signatum d Camrylwditor
"u�dicate Debw:
snea4 ciry. sbte, arN ZIP code)
age
antl ZIP cotle)
If yes. what munt7/.+
VJh
� u,� v�vem m a�esm�: a,N,aoy assessea
�Ftea� FrocenY 0 nrn,ua�y assessed
j-�� d �'� D
�, 2�Ly,�
couNTVnuo
��r
20 _ i zo i zo _
Counf,
I/ We ceNfy under the penalry of perjury that the above and foregoing infom�aGon i:
ovmer I conVac� buyer of the afwementioned property on date appliration is filed.
i�an,re (ownen n,u,arsre)
of appfimn (numDar antl shee4 �'. ��e, and ZIP mde)
Addre55 of auNd¢ed persa� (number arM SUee4 tify. slate. aM ZIP mde)
(1�5��
�.��� �
i � -.�8q i
�155, ��u�
daY. Y��)
�Y
� No
nd