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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship vear
__ + FOR DEDUCTION FROM ASSESSED VALUATION
• SlateFwm437091R11/6-09)
�' ,,,� 1 PresaibeG by OepartmeM of Lacal Govemrtrer�t Fu�ance
File Mark
INSTRUCTlONS:
To 6e filed in person w by mail wifh fhe Counry Audiror or County Recorder oi the oounry where the prope�ry is located. m��'
Fi/ing Dates: 1) Real Prope�ry: Must file during the year for which the deducfion is sought. � Auditor
2) Mobi7e / Manufactured Homes rrot assessed as Real Property Musf file dunrg the twelve (12J months C.
6efae March 37 0! each year ihe deducfion is snught � lY �
See reverse side for additional inshuctions and qualifications. GIBSON COUNTY AU D
App5cam (owne� m �� see resfirl1bns m r�rse side) �_ �'
x rea� p�opercy as
Y�
If name On reCad "9 tliRUen� Nan Nat Ol epp6w�1, htdlfal¢ bebvr.
Name of mortgagee or mntraG seiler
Address of rtartgagce ar mntrap sell
Name of assignee w other owner or h
�
AdCress ot assi�ee (num6er aM sUee4 �#l: sbte. an0 ZIP caCe)
Dces �nt own praperty in any oUC If yes, what munt�? ' What Taring DRViU7
munry in IMena?
❑ Yes ❑ No
��,��m�
zo � zo _ � x
Sigrianire W Co�mb Autlitor
1 I We certiry unAer Ne penalry ot perjury that the
owner I contraG buyer of Ne afwementioned pro�
a�l�
Dra�ver \0 ....:..............
Card NO• 3 J'"••••""
wUw�aed Dy O�Ay executed Power of Attomey or �y IC 61.142-0J
of authortretl person (numbeiaiM stree; cdy, state, and LP code)
rwmb)er Pag`gnuqlpej
�/ � /J �10
as ot Is ihe appfirant fhe sde
le�l a equilade ovrtwl�
❑ Yes ❑ No
spouse. Irtl�t'ate wrtn wnom
Is tlie propeM1y in Questiw�: MnuaDy Asse55ed
❑ Real ProPeM � ��Y ���
Has ihs Cetlu�fim Eeen re9uested m P�W�Y
(ar wrteru 1rcaR r� ' _ �--�
zo_ zo
Date (monfh. daY. Yxa�
ie applirant is a resident of Indiare antl