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STATEMENT OF MORTGAGE OR CONTRACT I 1 i )unty Township Year
FOR DEDUCTION FROM ASSESSED VALUATI
E
"A. State Form 93709(R11/6-09)
Presmbed by Department of Lod Government Finer
MAR 1 1 2015 File Mark
INSTRUCTIONS: .
To be filed in person or by mad with the County Auditor or County Recorder of the county w re the p pre Io Form rued with:
Filing Dates: 1) Real Property:Must file during the year for which the deduction is soug {/ E<ounty Auditor
2) Mobile/Manufactured Homes not assessed as Real Property.Must file ddMNg' )months
before March 31 of each year the deduction is sought GIBSON COUNTY UDITOR ❑ County Recorder
See reverse side for add pal instructions and qualifications.
AppGrant(owner or see restrictions on
re side)
Ta Distrkx Key n /legal description
Reco number Page number
c.-/9-09-Co- 000 ,55a-Dais aoi4
307/
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as a I Mortgage r u.,,.—_._ .dness unpaid as of Is the applicant the sole
Marti 1;anent year Mamlr 1,rs date of appficatun legal air equitable airmen/
�/��}/.'�/� ❑ Yes ❑ No
If no,what is his/her mad share of interest? ! If owned with someone other than spouse,indicate whh whom
If name on record is different than that of appacant,Indicate below: Is the property in question:Anrua%Assessed
❑Real Property ❑Annually Assessed
Mobile Home(IC 6-1-1-7)
Name of mortgagee or contract seller
at/ OuJ ;
Address of mortgagee or contract seller(number and sheet city,eta, ,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code)
•
Does applicant awn property in any other If yes,what county? • What Taring District? Has this deduction been requested on property
minty in Indiana? ❑ Yes ❑ No for current Yon ❑ Yes ❑ No
i COUNTY AUDITOR
Drawer NO ,9?OC 20 20 20 20
3o1 / County Date(month,day,year)
Card NO.
.. .. ..,,u,y mice,me penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
SIgnabae(o�)�/n:4ss,.ffo�ilr'nnaame) Date(Marra day,year)
resident address Wiz t numberand L o%state,and ZIP code)
�6y9 tiros FT Aka r A X171Vl d/a-753 -39YS
Perso authorized by duty executed Power of Attorney or by IC 6-1-1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code)
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