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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
_, s FOR DEDUCTION FROM ASSESSED VALUATION
. . n Stala Fortn 437091R11 / 609)
,�,,,, arPSa+nm cy cepertmern oi Loml cwemmem Rnance File
�NSTRUCTIONS: �
To 6e filed in person a by mail witA the CountyAuditor or Counry Recortier o/ (he county whem the property is located. F� 15 2011
Frlirg Dates: 7) Real Property: Must file dufig fhe year for which the deduction is sought. County Audimr
2J Mobde / Manufactured Homes rrot assessed as Real Properly Mus[ file durirg the fweHe (72J months "�' oun er
before March 37 of each year Ihe deduclion is s0ught.
See reverse side lor additional insWCtions and qualificatbns. GIBSON Cn� u�r., _.. _
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I( f10. wh2� 6 hl5I1Pl B%dL� ShNO Of 1I1[¢R5�?
=i�'�i=�aa_�. o:s� _oaa
A1o�tpape/ Contraa indebted�ress unpaid az M Mortgage / Conbad
Mart3i 1, artent yeer dale of aPpGCatiqR'
�1 furtie m �ecad'a 6RUrnt ihan Nat N applicant owk
Nartre at nartpa9ee or mntraa selier �
Atltlress of rtart9a9ee w mntraa seller (number and sa
Name ol assignee or other owner or hdder of nartgage
AdE2ss of assignee (number an0 svee4 �4Y. slete, and
Dces epplkarit o+m Woperty in any oNer
munry in IMiana?
❑ Yes ❑ No
Deduc7rn approved m tlre amoum oE
� �
SioriaNre of Co�mN AuditOr
wmeane
9E4 ciN. stele. aM ZIP aode) � /�
U v
ZlPcatle)
If yes, wlat munt�? Wtat Ta�d�g Di51nC?
COUNTYAUDROR
20 20 20
Counry
Record ny nb�
i
htNness unpaiE as of b
UU '&
�a �
spouse, ind'uate with whom
�,��
iilade o�v�
Yes ❑ No
Is tlre P�GertY in puestion: Mnue�Y AssesseA
�Real Roperty ❑ Armually Assessed
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Da�e (marfh. day,lee�
I I We certify urWer the penalty of pe�ury Nal Ihe ahove aM (oregoing infortnalion is true and cortect arM that Ne applinnt is a resident of IrWiana and
owner / wntraG buyer of ihe aforementioned property on date application is filed.
`I _.dna ! wneh hAremel Date (monfi. day, Yea�
�`/ Fu0 " (�nt atldr[
/ PasonaWw�¢eE
(number antl sheet, rdy, state,
of Attomey m py IC 61.1-12-0.7
person (numbererM sbceG dry. state.
�Y• Yae�)