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'°'n STATEMENT OF MORTGAGE OR CONTRACT N oun Township vear
__ � FOR DEDUCTION FROM ASSESSED VALUAT�� �
S1ate Fwm 43709 (Rit / 609) �
�' ,� Prescribetl by �epartment of Local Govemment Finarice
wsraucnoNS: SEP 2 6 2012
To 6e fiied in person of by mail with the CouniyAUditor or County Recorder o/ the counry-wherq�t�rty is located.
Filirg Dates: 1) Real Pmperty Must file dunng the year for which the deduction is soug7it J� �
2) Mobi/e / Manufactured Homes not assessed as Real Property: Must fi!e dunng the �Y) months
6eforeMarch3lofeachyearthedeductionissought. GIBSONCOUNTYAUDITOR
See reverse side for addRional instructions and qual�fications.
AnoGwnt (owner ^ trdct 6We see re se sidel �. .
wmber/legal
�1a�1,�
exad
name m femd s dMerent than that o( app6wnt,
Name of mortga9ee ar mntract
Aderess ot mM-' �
�
I�
�d�
Does ap_
munry in
selle� �
V
l.�0 g �
�d'
No
File Mark
Fortn t�ed
� unry Auditor
❑ County Recorder
�V �C�� I/ / S IO�— OOI. S� D� Remrtf numbrJ � Pagg numEe�, �
[; C�
�Con�tr�aG i/ntle6te�ness unPaid as N Mortgage / Conract "uWe6tedness unGaid as d Is ihe aPPllrent Me sole
"� S O� � tlate of aOP�� legal or epuitade amen
I ❑ Yes ❑ No
ff awned wiN someorre aher ihan sP�. irufrcate W�h whom
elmr. Is the v�PenY in Question: Mnualy Assesse0
_ - � ❑ Rea� aroaertr ❑ �w,ua�ry nsessed
Mod'le Home IC 61.1-7
��1�
�ZlPmde)
_,..w,ac co�oryr � w�i ra�re oabaz
Has Na dedudion Deen reQUested m property
for curtent ynaR ❑ Yes ❑ No