Mortgage_Holder^��4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS vear
__ • FOR DEDUCTION FROM ASSESSED VALUATION
~ S1ate Fortn 437W (R11 / 6-09)
�' ,,,, 1 Fresm'eea M�G�m ot LorW Govemmem Fuiance - File Mark
INSTRUCT70NS: D E C. 1
To 6e filed in erson or 6 mad with Ne Coun Auditor orCoun Recorder of the ceun where the lo F� ���
P Y N N �Y P PeenY is located.
Fdirg Dates: 1) Real Pmperty Must file dunrg the year (or which the deducGon is sought. �C .'�. � County Auditor
2) Mobde / Manufaclumd Homes not assessed es Real Property M�st fi!e dunng the tv+elve (12) rtanths
6efore March 31 of each year the deduction is sought. - Counry Recorder
See 2verse side lor additional instructans and qua/ficafions. G I B SON COU _
ano&ant (owaeru� mnbarl buNer- see reshirbora m reverse sidel _
T' Distr&Y Key number / Iegai desmptlan . Record numbei Page nurMer
-/3-a - o- ov• �8_3 -005! aoi,Z Sv�
Aseced rahle of real PW�Y az M / Contract inde6tedness unPab az ot Mptgage / ConHaU'cWebtedness un7aid as d LS ihe eOP�znt the sde
ra e
M2rt�h 1, acrenc ye3r Ma , wrtent yeer date ot app kpal w equitable rnmdl
�D (7 O D ❑ Yes ❑ No
If ro, what Is his I her e.xart share ol interast? H avmed win someorre oMer Ihan spouse, i�kate wlih whom
If name on remN is dfi�t Ihan Nat of aPP�l'cdinte 6elow ihe pmperty in Oues6on: Mnually Assesr.e0
� ��� ❑ d1�Iy� 1.1-i
or mntrati seAer
or ��� «
r�
�.a
Name of assignee w other ownet w twWer oi mortgage
Ad af assignae (numbaraM slree4 city, sfa2, eiul LP code)
T 8-z-
Dces ePPlinnt ovm property in anY oNer If yes. what munCJt
munry m IMiarm? ❑ Yes ❑ No
Ded�cOOn �PProved b
y� �
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20 _ 20 _ 20 _ 20 _ 20 _ 20 _ 20 _
� W CrnmN nueacr caunb oa� (manm. dav. YeaA
I/ We certiy under the penalty of ury that the a and foregoing infortnation is W e and cortec[ arM that ihe applicant is a resident of Ind'rana and
owner I mntract buyer oT ihe aforementioned prope on date application is filed.
i7�R+re (owne/s ND reme) ./ . Date (mor++h, daY. Y�)
address
� GO J� / �Q_i
ezecuted Power ot A[mrt�ey or Cy IC Gt.
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slate,
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