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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
FOR DEDUCTION FROM ASSESSED VALUATION �
• State Fortn 93709 (R17 / 6-09)
\ / Presmbetl M�� o( Loral Govamrtrent Fu�aru .—
File Mark
INSTRUCTIONS: �C P
To be filed in person or by maB with the County Audi[or w Counry Recortier o/ the counry where the propeM is locat �
Fitirg Dates: 7J Real Property: Must fi7e dunrrg the yrear /or which the deduction is sought.
2) Mo6de / Manufactured Fbmes not assesced as Real Properfy Must Re dunng Me hveNe (72) rmnths�,y/
befae Mamh 37 0! each yeer the deduclion is sayhG 9'«
See reverse side foradditional inshucUons and quali�rcatbns. GIBSON C
��Ma(l��t(mmerorconvac6uyar-see miaverseside) i D
Counry Audimr
Counry Recorder
Ta' D�striQ_ Keyrvmber/legaldrsoiptim - Recortlnumber Pagenumbri
- 9_p - 00-OOD. d5/-��.5 ao�o a31
Assessetl vWUe d re� PW�Y as d AWrtp� 9e I Contraa iMehteEness unpaid as of Mongage / Cantraa cMebtedness unOaiE u d h Me ePP�� tlre sok
Memh 1, a�d year Ms hic 1. airte�rt Y� date o( aOPa'�� ����� �
��n nn/7 n Yes ❑ No
It m. what Is h's / her e�a share of interest'/
If nazne on 2cptl e diffuent tl�an Ihat N appOmnt, 4Wrcate bebw:
Name of mortgagee or mntract selltt\/'�
Atldress d rtnrtgagee «mntrad seDer (number erH
�
�
Name of assi�ce w otlw awner w holder of rtwrtgage
ACCress o7 az�eP (number antl svee� tily, s�te, entl i
Dces e�ita�4 oxn property in any othc I �
munry in Ind'ana?
❑ Yes ❑ No _
Detlucfion approved in ihe amounc ot
rc ownae M;m m�a�e otlmr man w�e.
is Ihe P��Y in Vuestion: M�waOY Assessed
G'�� �r�nv ❑ ��N �
Moble Hmie OC 6
20 � 20 =
sgrienae m ca�mb �rtur �
I I We certify urWer the pe tty of perjury �hat ihe a
owner I contract buyer ot e aforementioned pro�
��re��(��e)W ��
Full �sident o! appfrcant (numberand st�ee4 �: y
(oos El000 S � c
Person aWn�d N/ didy rsecuted Power NAttwney or Cy
�
aM foregoing infortnation is W e and correcl arM ihat Ne applinnt is a residem of I�iana ard
n date application is fiied.
Data (monfh. daY. Y��1
antl ZIP coda)
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