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"�n STATEMENT OF MORTGAGE OR CONTRACT INDEBT'�UNESS_ Coun Tovmship Year
_ • FOR DEDUCTION FROM ASSESSED VALUATION 6-i fj t�] :�,
.� State Fortn 43709 (R71 / 6-09) .Y .g g J �"'�
�' ,� 1 p��-pyd yy p¢pa�nt of Lad Govemment Finance ��
SCf File Mark
wsrRUCnoNS: 2 4 2012 Fo,,,,m�a�n,:
To be filed in person or by mail with the CountyAudiror or Counry Recorder o! the county where the properry is located.
Filing Dafes: i) Real Pmperty: Must file dunng Ne year for which the deduction is sought �� �• h�� � Counry Auditor
2) Mo6i/e / Manufectured Homes rrot assessed as Real Property: Must file dunng the hvelve (�21 mapths
befo,e Ma�ch 31 of each year the deduction is sought. V C�\ ❑ Counry Recorder
See reverse sjd� /oradditional instmctions andqual�cations. G�BSON COUNTy q� �.pR
'iw�
�il10. W�Id� 6 �IIS / �1Cf CS2Gi
Key number
Nan ihat of aPpGont, udirate belaw.
Name ot rtrorigagee a mntract seller
Pddress of mortga9ee w mntratl seDer
Name of assignee w oNU avmer or I�daer m mutgage
ALdress of assi�nee (number aM stree4 �: stale, and LP oode)
Dces ePNi�2nt pm property in any ONM I( yes. what wunty7
counryinlndana? ❑ Yes ❑ No
D�uc�m appfo+eE in ihe amount
zo � zo
. � i �v� , � .�
1 I We ceNfy uMer ihe penalry of p�ury that ihe
owner I contracl buyer of Ne afaementioned pro�.
a��cs�#w„ame) � J 1 /
wAtmmey m
z,(.,L.J•S� �a��
� unpai0 as W Mortgape / Conn
mm�Ire
unpaid as
or
Yes LI No
Is Ne property in puestion: MnuaOy A,sessed
❑RealProPeRY ❑!!"^!!a��Y�
4Ma� Ta�dn9 DisUict7 I Has Iha
fa a�re
7,1U<v� � -
�o.v� �y�s��`����'`� _
�j,�e�U- L -
��S!v"lC1.t(��(��� -
Pddmss of aW�or'vE0 person (number arM sbee; dry, sfate. aM
�_
�� �,�m. a�Y,,�n
� P�P�'+lY
❑ No
Zo _
nd toregoing infortnalion is W e and cortect arid that Ne applipnt is a resident of Indiara arW
date appl'icatlon is filed.
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