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^�n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Townshi Year
_. � FOR DEDUCTION FROM ASSESSED VALUATION
• Sfate Fartn A3709 (R77 / 609)
�' w. � PresrnDed M �eP�ment ot Lacai Govemment Firiarcx
File Mark
rNSrRUCno,vs: NOV
To be fi7ed in person a 6y mad with fhe CourttyAuditor o� Counry Recader o/ the counly where the property is bcated. � '
F�7ing Dates: 1) Real Property: Must 6ie durirg ye year /or which fhe deduclion is soughG C.'�, County Audimr
2) Mo6i7e /Manufaclured Homes rrot assessed as Real Pruperty: Must file during the fwelve (12) months
before March 31 of each year the deduction is sought. unty Recorder
Seereverseside(oradditionalinstructFonsandquali�cations. GIBSON CO
Mpfr�"t (owne` m mwart buyu :see restmly�ys m leverse vde)
Tamg olsfirl Key rwmber / k9al descriPtion
� aCo -M19oR-pa�g8a -3�5<- 000 � sY r- o
Ass¢sed rahre dreal qoperty az ol I Alarch i, / ContrarY IrdebtEOness unpaid a of MMg.
Matd� 1. aY�ent 1'� aumnt Yee� date c
Ii no, what Is his /
tt nanre on remrd'a G�fferent Nan Wt of aPP�t tri0ipte below.
f�
�
Name of mortgagee v contraG uller �.
� �9a9ce a
stree; city, sb�, aMLPmde)
Name a( assi9nee w oNu ovmer or hdder of morigage
AEtlress of assignee (numbr! arM s1reeL �y: state, am
Dces apDiicant rnm prope�
munry m IrW'�ana?
Deduc6an approved In the
20 I
� -
I/Wea
� any oNer
Yes ❑ No
wnt of.
� I
under �he penal
act buver of the
rc �ea �;m
If yes. what munyl � I Whal T.
COUNTY AUDR(
i:��
����� P��Y98
unpaid as d Is Ne eppGrant the sole
Iegel w equita6le amnl!
� /7 n Yes ❑ No
Is me Droperty in question: MnuaAy A,sessed
�eal HoperlY Q ArmuallY 0.5ses5ed
MoWle Home OC 6
�. (.�S%�; . S%��� �
l�?,.5���
20 _ � 20 _
Caunry
�
yea�
uoperty
20 _
above aM foregoing infortnatlon is We end correct aM that the applinnt is a tesident of Indiana ard
�erty on date application is filed.
Fuo re9aenc aaaess or appl�nt {numner ana shee4 �y; srare, and LP cade)
�o'i F V:�.c Sr. F �+- Br4��
Pelson auNOi¢ed Ey d�Ay executed Power otAttomeY v by IC 67.7-12�.7
per„on (numDera� sbee; pry, sfate, and LP mtle)
76y F�
Date (monfi. CaY.
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