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-°•n STATEMENT OF MORTGAGE OR CONTRACT�}PIQE$�� Coum
= FOR DEDUCTION FROM ASSESSED VALUA�QN�
� S1ate Fortn 437091R11 / 6-09) )L
. �' Presvibed by DeparlmeM of Lacal Govemmenl Frunce
�+srRUCnoNS: OCT 1 6 2012
To be filed in person a by mail wffh the CountyAuditor or Counry Recorder of the county, where fd� e,property is located.
FAing Da[es: 1) Real Pmperty: Must �ile during the year fir which tha deducLOn is sought��' � (���
2) Mobde / Manu(actured Homes rrot assessed as Real Property: Must file dunng the�la�li�2) months
betaeMarch37o/eachyearthedeductionissought. GIBSONCOUNTYAUDITOR
See 2verse side (or additional inshucti�ons arM qualfiqtions.
MP� �(owrres ar mnhao buyer- see � ns m re rse side) �.
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Ta�drg Distr'xt , Key nwnDer / legal desaiption
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Att� vdlu
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11 no. wha� Is h
It rwrre m Rc
A�ress
ptope*CJ az
Nan Ihat of appGcant, 4Miwte below:
or mno-aa
tlier owner
slate,
File Mark
Fortn t�eE with:
�P�1.� County Auditnr
/ �Counry Remrdu
number
hte0/ne(ss unpaiE as W Mortgage / ContraU hWebteOness unpaiC as d Is Ne eppWant Me sde
SV date af a7P�� kgal or eWitable oxnM
❑ Yes ❑ No
If awne0 with mmrore olher t�an sD�. ud'xate Wih wlrom
[�tM P�7eMY in CuesUm: MnuaM Assessed
� Provenv ❑ ivmualyAssessed . - -
AEtlress of assgnee (numoer ana saee4 �'. �+e, ana t�r caoe)
Does e�imnt axn property in eny oNu If yes, what muni�?
oouiLLy in Indana? ❑ Ye5 ❑ No
oeauctlon appfovea'v� me
W�a� Ta�g
D �-�„���� . o.a4! a .:....... ._
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Card NO. ...5:1;'y I —
.......... No
�t��,y 50. °°_ -
zo zo zo zo _ zo _ zo _ zo _
Sig�aerte W Camblwditar Caunry Date (rtqrvh. daY• Y��)
I I We certify under ihe penalry of perjury Nat Ne above and foregoing infortnalion is true and cortect arM that the applicant is a resident of I�iana and
owner I mntraG buyeryjl6y aforementioned property on date appliradon is filed. .
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Pason aulhoracd Gy dWy exeaRed Power ot AUbney or by IC 61.7-72-0.7
AOer�s of authoraed persan (numberantl sbee4 �N, sb�e, e+M LP code) .
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