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/ "'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Co 7ownshi vear
/. , FOR DEDUCTION FROM ASSESSED VALUATION .� �
� � � State Fwm A3709 (R71 / 6-09)
�' w. � ProstriEed by DePS�M of Laal Govemment France
Fle Mark
wsrRUCnoNS: �^��
To be filed in person w by maii wifh the County Auditor or Counry Recorder o/ tha counry wFiere the property is located.
F�7ing Dates: 1) Real Property: Must fife durirg the year Por whifh the deduction is seught ��ry q���
. 2) Mob�7e / Manufactuied Homes rwt assessed as Real Property: Must file during the tweHe (72) months
6efore MamJ� 37 0/ eadr year the dedudion is �ht �� ��
Seereversesideloraddition�linsfi�ctbnsaridouelfications./"1 GIBSO t, ITOR
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Name of mortga9ee a mntrsct u-0er
Mdress of rtartgagea w wntraa seDer (rnm�bv �d stree4 �N. sbte, aM LP
Nameafass:—'_. .
� , ao ►�
n�e�asswaa DI':1\\'Cl" L�� ...................
� e�� � o. ..... y51`�
C�C(� \ .......
$ 15�J,�� _
oea�caa, �p�wea m tlre ama,N
20 _ � 20 _ I 20 _ ( 20
I I We certify
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/- dtX7-�333-Cb�/ I "�'"""'"°� I
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,,, ��o��� ��a
W�at Taarg Districl7
20
Yes ❑ No
Is tlie M�P�Y in OuesOm: MnuaOy Ass�suE
� Real PtoPertY ❑ M!u!a11Y Ass�s�
��,�
Yes ❑ No
�— � p—
Date (rtmN. daY.
tha penatty f perjury that �h bove and (oregoing information is true and mrtect and that the applinn[ is a resident of Indiana ard
yer of the mentioned rty nn da[e application is filed.
� Date (monlh. daY. Y��
ippfmant ( r antl sbeet �: sbre, antl IlP mEe)
7SQ'S /) avs �, ��� � . '-/7 L �s
y erzecuted Power of ey rn by IC 61.1-12-0.7 Date (rtrorrth, dfi: Year)
MEress ot autlmf'veA D� (numbe� antl sveeL �Y. state.
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