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^�n STATEMENT OF MORTGAGE OR
: FOR DEDUCTION FROM ASSES�
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State Fom 497W (R11 / 6-09)
�` - ? p��6ed M OePartment of tn�al GovemmeM Fruna.
�raucnavs: DEC 1 9 2012
To be filed in person or by mad with !he CountyAUdifor or Counry RewNer of Ne�o!{n e property is located.
Fil'mg Dates: 7) Real Pmperty: Must file dunrg the year (or which Ne deductlon'is s�
2) Mo6de / Manufadured Homes rrot assessed as Real Property: Must fiie duri h Ive (12) months
6etore March 3l o( each year the deduction is sought.
GIBSON COUNTY AUDITOR
See iever�side (or additional instructrons and qualific�tlons. _
�/�,(/h�°Q � � I �Y
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Mardi 1. aa�en� Year
rc �o. wnat ts nis / her e�t dw�e or inte`e
If wne m Rcud iv ddfumt Nan Nat af a
Nart�e of mortga9ee a con�ffi seller
Address of mon9agce w mntra�l se0er (n
Name of azsi�ee or oNe.r ownrs m hdde
side)
File Maric
Fo�„� mea wnn:
�f'.ounry Auditor
❑ County Recorder
- i'a -og -�03- ood . o �L 6 aa� ..�_._. _.. . 5�7�"
e/ Contryat�t Intle6tr�ness unpaid as ot Mwigage I Contraci indehtedness unpald as of Is Ne epp�ont Ne sole
`J O�O^ tlate of app�ptan �egal O�e O N
U
tt awned wi� someone oihu than spouse. indkate WN whom
indirate Eehw.
AECress ot assi9nee (number arM atree4 �: state. end LP cotle)
Dces ePPliontovm P�PenY in anyoUer .If.ves.whm m��ry?
cauncrin.lndo�n���—
1 �U R�ss, �a�gv �'` _
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]UNTYAUDROR
20
Caunry
Is tt�e property in quesoon: l�+nuelly Assessr.d
� Real P(Opefty � NmuallyA55essed
MaW1e Fiarne fIC 61.
y�a
zo— i �°—
Date (rtaonttr, day,
;ted m p�apeity
v� ❑ i
zo
I I We certify under ihe penalry of perjury Nat the above and foregoing intortnalion is We and cortect and �hat the applitant is a resident of Irrcfiana and
owner I contracl buyer of the ataementioned property on date application is fiied.
irewre Ibwne(s fWl namel . i . __ i. � Date (/riwi+h. daY. We�
of Atbmey or by
W author¢ed 7erson (number and snee4 uty. state.
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