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^'�a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun To ship ea
• FOR DEDUCTION FROM ASSESSED VALUATION
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' Sfa[e Fwm <3709/R77 / 6-09)
�' „�� � presrn'bed by �epartment of Lod Govemrnent F�wice
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To 6e filed in erson or b mail wifh the Coun Auditor or Coun Rewrder of the coun where the ro FO� m� �:
P Y �Y N �Y P PertYislocated. C.
Fifirg Dates: 1) Real Property: Must file during the year /or which the deductlon is sought. � ly d���
2J Mo6Ae / Manufac[ured Homes not assessed as Real Property: Must fife dunng Ne hvelve (12) months n
bePoreMarch3lofeachyearthedeductionissoughG GIB ON"COUNTY UDITOR
See ieverse side /or additional instrucGons arM qualifiptions.
Ap t(owner or tontrarl6uyev- see resbic8dls on re�+erse side) �
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TaAn9 isbiG Key �umiber / legal d � tron Recad numbrj Page riumbej
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A�ed valua d real propeM1y at W MoK9a9e 1 ContraG 4We6tedn�s unpaid az of Mortgage / Cm'vafl iMebtedness unD� as d Is the aPP�t the sole
AUtU 1. avmnt yrar Marrh 1 year date of aPPfmatnn legal or itable oxn�
'°�'t � ❑ No
H ro, what b his / trer eraU share of interesi? tt awned with wmeane oihv ihan sWuse, IMkate wlth wtwm
tt nama on remE is ddferent V�an Nai ot appfranL'udinte helmr. Is Ne property in Questim: Mnualry Assessed
Reel RoPenY ❑ �Y �
Modle Home IC 61.1-
Name W moNgagee w conVaG seller
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Add of rtmrt9agee or contraG seller (nuriber aM sfree4 �1: ��. aM LP code)
Nama of assi9nee or othu ownu or hdder of mortgage
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I�,� _ _ _
AddR53 of a5signce (number eM SLeeL d1y, s:ate, anC LP Code) –,"- —
Oces applinnt awn property in any oNer If yes. what munry/1 YVhat Tarirg D'strirlT ,-{�
counry in IMaia? ❑ Yes o ' � j �� I V/�•-'�,•5 •••• ••
U�•:I�VCT \�..........
COUNTY AUDROR � 4 �, , l . . . . . • •
DeducCOn appmuad in the amount of. � Q..•
Cal'd
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signawre d Camb nuanor caunry oace (muh� da�: yea�
I/ We �fy u Ne natty rjury that the above arW (oregoing infortnation is true and cortect arW Ihat the appiipnt is a resident of Indrana aM
own n u of Ne me�med property on date applicabon is filed.
wne ) trdte( daY.Y�a�
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msidenta0tlress� t( her�sLee4�Y�te. � LP J/ �'f'��O ^
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Person authar'¢eE by dWy esewteC Pawer ol y or by IC 61.7-12�.7 Date (rtunM, day; yea�
Pddress of aNha'¢ed person (numberand sneet �+4'. sbte, aM LP ootle) .