Mortgage_Boyle^�� STATEMENT OF MORTGAGE OR COP
__ • FOR DEDUCTION FROM ASSESSED
State Fortn 43709IR17 / 6-09)
�` presoibed Ey Department al Lod Govemrtrent Fu�arrs
INSTRUCTIONS: Cr {p—�qi_6�.ZO3 G�o��CJ 6Z � DEC 2S 2012
To 6e lled in person or by mail witA the CountyAUditw or Counry Recorder of the oounry r� th �s bcated.
Filirg Dates: i) Real Pmperty: Must (le dunng the year for which Ne deduction is sought. � ��
2) Mob�7e / Manufactured Homes rwt assessed as Real Property: Must file dunng Me ( rtwnths
beforeMarch37o/eachyearthededuclionrssought GIBSONCOUtdTYAUDITOR
See reverse side for " instructions arM qualificatbns.
�
buyer
AswsseC vWUe d real poperry
Ma�[�h 7, nnefrt year
If no. wha� is hi5 / her exaf2 sh
If name an m�ad 6 drtfrlent tl
Name
Nat of app6ranL mdirale �ebw:
AAdress of �mrt9a9ce or cmtracl seller (n
Na+ne of essignee or other ownet or hdde
M42ss of as9gnee (numberaM streeG �
Ooes appliCant own yopeM in env nNr �
��.
co0e)
❑r
�
�
File Mark
Fortnl�ed�' .
County Auditnr
❑ counry Recorder
Page number
1 az W Mortga9e I ContrarY uMebtedness unpatd as of Is Ne aPP�t Ne sole
data of epplxatirn kgal or equttaWe ownerl
❑ Yes ❑ No
tt awned wiM �rie aher ihan spouse. 4Nkate wNh xlrom
Is C�e P�PenY m Cuestim: MnuaM Assessed
❑ Real RoaeM ❑ Annua�N Assessed
trbb0e Fiome (IC 61.1-i
Has Nis dedud'nn Deen reQUested on propeM1y
for wrtent yeaR � Yes ❑ I
�a' �/� COUNTYAUDROR
— t Ul .........
duc • ' '
pl a`�.�1• \ ..
z� �q I �9...... zo_ 20_
Card \O. ..........
,�„ - ���
II
I/ We certfy under Ne penalry ot �ury Nat the above an r oing infortnalion is We and cortec[ aM that the
owrye[ I contrad buyer of Ihe aforeme`rtioned property on t appliration is filed.
(num6erandshee4
2a_ 20_
�� c�m, e�r. r�a
pplitant is a resident of Indiana aM
Da (mw+fi, day, yaa�
��. ��_ 7/i /�1
a�WOmyy py d�ty exewv.y Pawer of eY or C 61.1-12-0.7 I�� (�N. �Y. S��
s oi author¢ed perso� (number aM sbee4 �: �te. end Z1P ootle) .