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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Townshi vear
_ < FOR DEDUCTION FROM ASSESSED VALUATION
� � SNate Fwm 93709 (R77 / b-09)
S PresviOetl by DepartrtreN of Laal Govemment Finance
� Fite Mark
lNSTRUCTIONS: MA fl
io 6e fi7ed in person o� by mail wr[h Me CountyAuditor or Counry Recorder o/ the oounty where fhe property is bcated.
Fr7irg Dates: i) Real Pmperly: Must file dunng the year for wliirh Ihe deducLOn is sought. unty A tlitor
2) Mobde / Manu7actured Homes not assessed as Real Property: Must fiIe dunng the hveNe (12J months
before MarGr 37 0/ each year the deduction is sought. unry Recorder
See reverse side tm edditiona� instmctions and qualfications. GIBSO N
M9��P�(ownelorcontraepyyer-see mrererseside) . . �
' Districl Key number! legal desoiptim Recotd numCU Page number
a(v - a,-o - tioa - ooy. � 30 -v g aoi �
�essed vehre d r� pfopuq as of Mortgage / ConbaC iMehted�ss unpai0 as of hbrtgape / Contraa indehtedness unpaid as of Is Ihe applinnt Ihe
ardi 1. amPtrt year Me� 7. alrre�rt year Eate of aVPOtation k9� w eWilable owneR
Qv ❑Yes ❑ No
lq.Wi1316�tl5/hPIBYdf15�12180i1f1}P125i� �(OMICdW1I)I50(IIEOIIC VIdfI5pOU5E.TQIWiCM'l1�IW�1WP
`wria m reowd is dfieienl Nan that ol aPP��t uM'uate 6ehxc Is tM properry in Guestion: MnuaAY Ac^xsse0
eai PfoPertY ❑ ?�^^!�r1 `�„_ _ . . .
Name of rrortBa9ee or mntrad SWer
Addrea of �mrt9a9ce w mntrad
(number aM street tlry.
Oce5 aQplk2nt ovm property in any oNer I If yes, whet Count�?
munry u� Indiana? ❑ Yes
❑ No
' 1/ / ��-
What Tadn9 D'atrict? Has Ns d� Ecen rM�g�� � 7�nY
���� ❑ Yes ❑ No
COUNTYAUDROR 1, �
Dr�ucCanaOW�d'uitheamountoE LI'�11"CI' �TQ....���.�.....
20_ 20_ 20 20_ 20. CaI�C� 1��0. .......I
.... ........
Sig�nue rynud'aor . Counry .
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I/ We certify under the penalry ot perjury Ihat the above and foregoing infwmalion is We and cortec[ and that the apputam Ss a� to..�.„ ... ..._._ _. j
owner / contract buyer� f Ne afo2mentioned property on date application is filed.
(owner's fWina el Date (monfi. daY. Y��)
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ammev o� w ic s�,.,-,zo.�
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Pddr� N auNOraed Gg� (numberaiM sLee4 �: sfa?e. anE LP code) .
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