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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship vear
_. • FOR DEDUCTION PROM ASSESSED VALUAT� ���
�• Sfate form 43709 (Rt 7/ 6-09)
�' ,�,� Presaibed by Department ot loral Govemment Fuiance
File Mark
�+srRUCnoNS: OCT 1 5 2012
To be filed in persa+ w by mail with the CountyAuditw or Counry RecoNer o/ the county where the poperty is located.
Fifing Dates: 1) Real Pmperty: Must file during fhe year fo� which the deduction is soug rt.. �J.
2) Mobde / ManuFaclured Homes not assessed as Real Property Must fife dunng the fweNe 12J months
befae March 31 of each year the deduction is sought. v v
SeereversasideforaddifionalinstructionsarMqualifications. GIBSONCOUNTYAUDITOR
AppGnnt (ownei a contrau 6 see reshiCnns m re�rrse vde) n
KeY numbel/ legal desviption — ' /
a�-�� ��-�-�.�o�
Mw�aeAe / Contract inde6tetlness unnaid as ol MorL
Ii no. wha[ is his I
If nazne on reoortf is d'Aferent t7�an Nat ot
Name o1 mortgagee «mntretY eWu
�t rtnrtgagee ar mntrad seGer (nvnbrlend street �Y s7a�. aM Z!P code)
u
ll�-�„���� �o:.ao�a........
Card NO. ......°2`i 1..........
Aearess of z
ooes ep,iic
munry in Irc
20
- � I 0'li o� • �
a{,F.ww m me amoum ot
Co�mry AuCitw
20 _
�
H ovrtred wiN sameone
NRat ierirg DiStrictT
COUNTYAUDROR
20 I 20
Counry
E'' �'r,'_
Form Ned with:
�CountyAUdiWr
Counry Recorder
Remrprum� � P�e
O( Il
unPaid as of Is Ne ePP�?
❑ Yes ❑ No
Is iM property in quesCOn: MnuallyASesseE
] Real ProPenY ❑ �^�N�d
s U's deduGion Eeen repuwted m p�oputy
arrent yeaR ❑ Yes ❑ No
20 I 20
I I We certify urWer Ihe penalty W perjury Nat the above aM foregning infomiation is We and cortect and that the appiipnt is a resident of Indiana aM
owner % contract buyer of the afwementioned property on date appliratlon is filed.
�rewre Spwners hAI rteme) . / �% . Date (morvh. daY. Y��
FWI resia§ni address of appfzant(rylmbe� a 4�+N �te.
� ll� s, ,�'��u� �1. �
Per'.,on author�d Cy E esewtetl of Attortmy m� S'
Pddmss of authu'¢ed person (numberantl strae4 �: sbte. a�M
� I�h. �r, i�