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^�4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
� FOR DEDUCTION FROM ASSESSED VALUATION
• r . �, State Fwm 93709 (R71 / 6-09)
�- 1 p�p� py p¢py�nt of Locai GovemmeM Finance
File Mark
INSTRUCTIONS:
To be filed in persan w by mad with the CowrtyAudito� or Counry Recorder o/ the county where the property is located E B F 'w:
Fifirg Dates: 1) Real Property Must file during tha year for which the deduction is soughG � Coun Auditnr
2) MobJe /Manufactured Homes rrot assessed as Real Property: Must Re dunng the lvrehre (12J rtan
6efore March 31 of each year the deduction rs soughG • County Recorder
See reverse side (or addrtional instnxtions and qua/ficalions. GIBSON CO
App4rent ownerwcontrac`tb^uyu-se^e/ mreverseside)
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i T . ..ri Key nunhel/ k9al EesaiPtim Reco�d number Pa9e number
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raM d rral poperry a d Mortgage/ Contract irde6tednrss unpaid as of Mortgage / ContraG udehteMess unpaid as d Is ihe appGnnt fhe sde
1. aa�ent year MafM t. artent year date of ap legal a equita6le axneYl
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tl m. what Is his / her euct share of interesi? if avmed vriN someone other tlan spo�sa. IMkate with hiwm
If tume m temntl "s d�:ferent Nan that ot appB�e�it cd'uata hebw:
Name o( morVi agee w contrarl seller /f � �—y�
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Add'ess of mortga9ce a mntract seller (nurtibe� aM stre8; cify; sb
Name af asvgnee w othrJ ownPr or holder of mortgage
P.Odmss o assi9nge (numberarM s7ree4 �: �e, arq LP FWe)
Ooes aOPhmnt own Pe+ry in any er I( yes. xfiat
munryinind�arial � Ye .0 No
Dr�umon aooroved In tlx amount oY.
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I/ We cerV(y under the penatty of perjury that ihe above arW foregoing infortnation is W e end cortect arM Ihat ihe applicant is a 25ident of Indiana aM
owner / mntract buyer of the aforementioned property on date appfication is filed.
�reyre (ownerS h�imme) �l . . Date (nenW�. daJLY�
Pddress
(num0er
cotlej
c— u4c��y �'Ass , �-+A�tt3sTa
W Dy duly execu:ed Pav.er al Aimrtmy or by IC 61.1-12-0.7
state,
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