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"� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Co To vear
_ • FOR DEDUCTION FROM ASSESSED VALUATION
� srne Fom as�w cRii � sas�
4' � Presrn'hed q' DeP�ent of Laml GoremmeM Fuwce
�vsrnucnoNS. �AN F
To be lled in person w by mad witA the CountyAUditor or Counry Recorder o/ the county where the properry is Iocated. Farm Aed uiu:
Filirg Dates: i) Real Property: Must fiJe during the year lor which the deduction is sought. i��
2) Mo6�7e / ManuFactured Homes rrot assessed as Real Pluperly: Must file during fhe hvelve (72) months
befae Mamh 31 ofeach year the deduction is mughG � GIBSON p A� Recorder
See reverse side !or addtionel instructions and qualifications.
np °r c9^�raq buYe/' ife reY+icn°^3'9P* Y�� �e) � ' //
—Vl� —'TC�CJ' c��
� / ConhaG IndehteEness unP� az
a�rten[year
It name on recwd is Gdferent Nan Nat of aPP��L bdirate Eelow
rUme m monqasee «
Addres of mort9a9ea or mntract
awner w
�L �Y%16 s+dte.
Does ePPlifant wm p(operty in any oNer I If yes. wha[ count�?
counry in IM�ana? ❑ Yes ❑ No
DeCuc6on apPrm�eE tr� Ne
zo_
sigrunue w Coimd nwP�ur
20 _ � 20 _
'code)
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WhatTadfg D'strict?
COUNTYAUDROR
20 _
�^h
I I W� certfy urWer the penatty of perjury that the above antl foregoing intortnation is m
owner I mntract buyer of the aforemenUoned properry on date application is fiied.
FW residen[ aEQress o1 appGrant (number ard stree4 �1: sfate, aM LP ootle)
s!s'G S. 7?S�-tl Ou�P.sv;lle , Iit/
Pason aufhortrcd Dy EWy ezewtetl Powet otAttaney ar Cy IC 61.7-12-0.7
Pddress of authw�d pe�son (number and stree4 �Y, sbte. e� LP oode)
RemN numbel Page numGu
-C�-� a0l3 $90
:ontraG 6We6teMess unGaid as d LS Ne ePPGranl the so4
Yes LI No
QuesEOn:MnuaDyASSesseO
Assessed
ry r.w�i� nc s
Has Nis tletluGion Oeen reGUested on propelty
� w� �r ❑ Yes ❑ I
aas o -' —_°—
� ai.� I -
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