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STATEMENT OF MORTGAGE OR CONTRACT INDE
Sti i County Township Year
.- ; FOR DEDUCTION FROM ASSESSED VA
s4 State Form 63709(R11/6-09)
Preunbed by Department of Local Government Finance
201 File Mario
INSTRUCTIONS: SUN Forth fled with:
To be filed in person or by mad with the County Auditor or County Recorder of the county where the • ••- is boated.
Filing Dates: 1) Real Property Must file during the year for which the deduction is aught t rj ® County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property M e•61- -44/91991 elve( months
before March 31 of each year the deduction is sought III,GGUNTY AUDIT v ❑ County Recorder
See reverse side for additional instructions and qualifications. . GIBSO
Appacam(owner Of contract buyer�-see fe� �/s on reverse sidey r
�i�Hrr0qe--in nri. 40 C Y I!L_/ Co (/�C'//
r •- DistriU Key r ei/legal description Record number Page number
olr—QJ/ I Rem- /8- 01n -Rio 000 00 7 o a / 'C3 agg''/
Assessed`value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the anagram(the sole
Mania 1,current year March 1.anent �y7 data of application legal or equitable owner?
(07 Y-2.'l. El Yes El No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is dMerant than that of applicant,indicate below Is the property in question:Annually Assessed
Real Property ❑Mnualy Assessed
Mobile Home QC 6-1.1-7)
Name of mortgagee or contract seue l c,// Ysr "' J
'T l/
Address of mortgagee or contract seller eer(( um
nber and street,city,state.and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,thy,state,and ZIP code) /c��•'1 _
Does appcant own property in any other If yes,what county? - What ���� �'', Q /r 'f} rperb
many in Indiana? ❑ yes I Ga 'V`LJ E ❑ No -
❑ No �J/ /
COUNTY AUI • .& `
Deduction approved N the amount of:
20 20 20 20 - --_ ��1�8Sy .0_
I
Signature of County Auditor County Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
X:. pwnesnanaF). Club Date q-/3
Fug — C fappfscam(num rand tt ary,state,and ZIP code /'�Q` 1. GG �� K�C /03 e'3 1i. D/cL Pith!e e Yoh pl. Lw „3,,,/L 4 /- )
Person au duly exemted Power of Attorney or by IC 6-1.1-12-0.7 - Date(month,day year) L/7 h W�7
Address of authorized person (number and street ray,state,and ZIP code) .