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"'n STATEMENT OF MORTGAGE OR CONTRACT IN���SS un 7ownship Year
• FOR DEDUCTION FROM ASSESSED VALUATIO
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s�e �m, ea�os �n i s as�
S,«• ° Presrnbed UY DeV��ent of Loal Govemment Fraxe
File Mark
wsrnucnoNS: NOV 1 5 2012
To be filed in person or 6y mai7 with the CowrtyAudito� or Counry Rewrder o/ the counry where the pro �s bcated. Fam med witn:
FiTirg Dates: 1) Real Property: Must file dunng fhe year (or which the deduction is soughLC .'J. h\v� �°' Counry Audrtor
2) Mo6Re /Manufactured Homes rrot assessed as Real Property Must file during the hve (1 onths �
before March 31 of each year the deduclion is sought. � �.� County Recorder
Seereverseside/oraddifionalinsfructunsandqualfications. GIBSON COUNTY AUDITOR
M ( waneaebuyq-sea�smre.eisesde) �
� J%n r.,l w- JJna��- __ �� n�,n on.
T' DistriG Key numher / legal d�{aiptlon
�-ZD- -.3
Ass�Sed vdhre o( real WoPertY B9 Ot Mor(gage / Conb2tt 4dEhl
Ma�di 1. amrnt yrar Maich 1, wrtent year
�o L/
If ro, what �S his I her euct shara of interest?
I( name m remtl b Qrtfemrt Nan Nal of aPP�4 hid'xate bebw.
Name W mortgagee or contrar� seller� , e �� �
Tllhirr�
Addres W rrort�jagee w mntrsct seAer (nurn8e` end saee; ci1y, sbte. aM 2
Name of assignea or otfiu ovmer ar twlder of mortgage
ACtlress of assi9`ree (numberarN sUeet �N: s+ete, and LP coda)
Ooes applinN rnm ryoperty in any oNer If yes, wha[ muntyl
counryinlnd"ana? ❑ Yes ❑ No
pr�uctipn approved'c� pre artwnt aF.
20 _ 20 _ 20 _
Sigrewre d Camb nWitor
az
Recoitl numbel Page numbet
-00/ o 5�638'
' Conuxl trMe6tedness unpaid a d Is the ePPOrartt the sok
�fimtmn legal ar equitaWe ovmeYl
❑ Yes ❑ No
R owned wiN someone other Ihan sPOUSe, mdimte witli whom
Is Me Pmperty in Vuestior� Mnua11Y Pss¢ssed
� RP21 PIOPeKY ❑ Ann�a�Y Pss�d
Modle Fiome (IC 61.
� D�-�,;.�,� .io a�! a......... P�
Zo
GOUNTYAUO Ci11�CI � O. .� (O F� �. �u . • —
o( y
20 _ � 20 _
County
20 _ � 20
DatE (mw+lh. d3Y.
I/ We certfy u�er ihe penaliy of perjury that the above and foregoing intortnation is true and cortect arM that the applirant is a resident of Indana ard
owner I wntrad buyer of the aforementlmed property on date applicatlon is filed.
�re (owner3 !u0 imma) ,. .... �� Date (rtrmfi. daY. Yge�
by dWy exeated PaMer of Attmmy or by IC 61.1-12-0.7
�Y. Y��1
ACdress Of auNw"¢eE pCmAn (numDe�antl streal, Ctly, State, entl LP mtle) . I
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