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"na STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES n ship Year �
_ FOR DEDUCTION FROM ASSESSED VALUATION
. ' srate r-orm a97o8 (R71 � s-wj
t` ,.�. p�¢s�ibed by Department of Lnml Govemment Finance
wsrRUCnoNS:
NOV 15 2012F��eMark
To be filed in person w by mail wrfh the CowlyAuditor or County Recortler of the county where the property' Fam med wi�h:
Filirg Dates: i) Real Property: Must file dunnq the year (or which the deducfion is soughf. - I�'� � County Audimr
2J Mo6Be / Manufactured Homes rrot assessed as Real Pmperty Must file d�ring the M1velve (12) months
befaeMarch3fofearhyearthedeductionisscunght. GIBSONCOUNTY UD RCountyRecorder
Sea iev e side lar additional instrucWns and qualifications. �
IM ownerormntrae6uyer-seerestrice'onsonreversesede) � �
0.s�eC raqm d �
Marh 1, arrent year
If m, what ts h'a I her e�ct share ot interesi?
-o/�t/ga-,2 5_
March leairtentyear
tt nane on rem�d is N.7erenl U+an Nat ot app&anc, uWicate bebw.
nr :n .-:i
_ DOD, p0 -Od. %
s Unpaitl as o( Mtxlgaqe / Contract @M�
date o( aPPGmtio^0
I
..
It oxned with someone oNer thar
of mortga9ce w mntracl se0er (num6rl aM sveeS GN. s+ele, aM ZIP oode)
assignee w otfiu owner or hdder ot rtnrtgage
of assgnee (nurtiberaM svee4 �N, s+a:e. and LP code)
Dces ePDlirant own WoPertY
couniyinlnd�ana? �
ieron appro�red m ure ama,m oe
20 20
I/ We certify urWer the penatty of
owner I mnhaG buyer of the afor
Person autFw�aed by
:�.m,�.r_ � . .
Rew�d number Pa � number
�� / 3
6tedness unPaid as d Is Ihe aPPfinnt the sole
Iegal w equBaWe amerl
DD� ❑ vrs ❑ No
sGOUSe. mdxale wlth whom �
�Ips ih.�e pioperry in 0��: �nually Assessed
6J "eal ProPeAY ❑!vm!mMAss�sed . . .
_ '-�—
�l� 9, 8s�. �a� -
D�-a,;.�►. �ro.. a.o.�a
..........
Card i�'O. .....���.3
20 20 LU
� �+N �� (�. �r. reaA
that Ne a and foregoing iniortnatlon is W e and correc[ arM Ihat fhe applirant is a resident of Indiana aM
nention�perty on date �ficatioQis filed.
,. � Date (monfi. daY• Ya8�)
P
of appOpnt (num6e�and sbec stale, entl
✓. 3 SO S. �.�n/!'
w by IC 67.142-07
person (number arM sbee; ciry, sfate, an0 LP ootle)
r�d
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