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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS �un 7ovmship Year
_,�_ .� FOR DEDUCTION FROM ASSESSED VALUATIO� ��
� suce rbm, a3�os (an i s-w>
�' � Presmbed M DeP�em ot Lad GovemrtreM Fi�nce
File Mark
iNSrnucnoNS: DEC 1 3 201Z Fo,,,,m�a�m:
b 6e filed in person or by mai/ with the CounryAuditor or Counry Recorder ol the county where the property is located.
Fifirg Dates: 1) Real Property: Must file during the year for which tha deduction is sought.0 .'J, �unty Audimr
2J Mob�7e / ManWactured Homes not assessed as Real P/npeRy Must fiie during the 1 months
before MamJt 31 of each year Ihe deduction is sought - d ❑ Counry Recorder
Seeleversesidefor ddtionalinstrucuonsandqualifi tions. GIBSONCOUNTYAUDITOR
MaGmnt (owrrer uy�C� see�{eshi�au oP 2 3eFe)/J _ _ .
ro,
If nartce m record is Qf,lerenl than Nat of app&:ant, uidicate 6ebw:
Name at mortgagee v mntraa
Addrea
oMer ownel m hddu ot
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IX �J�T"Y� � MV� �
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� CAssa u oQa 2
6 1�- (�03r1
57affi. BM ZIP code)
nunp?
2� _ � 2� _ � 20 � 2�
I/ We certify under Ne penalry at perjury Ihat tf� above and fa
owner I contracl buyer of ihe afo2mentioned property on date
sate,
author'¢ed Dy Ouly ezecu�ed Power of Mu�eY w M IC G7.1-12-0.7
Pddres5 of a�nha¢etl person (numDerantl sLeeL m3: slate,
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�t awned wi;n
NR13t Tadtg OStrit[7
zo
antthasok
ii�he mmeYi
Yes ❑ No
spouse,
Is ihe properry in question: MnuaM nsesxd
� Real P(Operty � AmlualyA55essed
Has Nis deductlon
for artent YeaR
xo _
t�ww,. aar r��
� D�Y
❑ No
zo _
�rtnation is W e and cortec[ ar�d �ha[ ihe applinnt is a resideni of Indiaria and
is filed.
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