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""� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__, FOR DEDUCTION FROM ASSESSED VALUATION
� 51ate Fwm C3709 (R11 / 609)
,' �«. 1 Presmbed Ey DepertmeN ot Laral Govemment Fuwce
File Mark
wsrRUCnoNS: AUG '
To be fried in person w by maii with the CounryAudROr or Counry Recorder of the counry where the pioperty is located. '
Fi7irg Dates: 1) Real Pmperty: Must fde dunng the year (or which the deduction is sought � Counry Auditor
2) Mobde /Manufactured Homes rrot assessed as Real Property Must file dunng the hvefve (12) monthy� �,�!�
befo2 MarCh 37 of each year the deduction is srought. a�� , h��/.Counry Recorder
C/
Seereversesideloradditionalinst/uctbnsandqualifications. GIBSON COUNTY AUDIT R
�/ ewner ,�' n uyqy � wiraou m r veOC��ni�J
.xAl��l'./ U
Tan` Oistritt � Key �wmber! legal destription Retotd numbet Page wmbrr
�o - 0-03-�00- oo. �39 y-oo/ doo� a.s'
Asessed vahie rA real prapaty az d Mortq age / Contrau intlebtetlness unGaid as W Mortgage / Con� iride6tedriess un4mid as o( Is ihe ap�t Me sde
'MaRh i. aarart 1� Mert3� 1. airterrt date of aPP��^ le9al w e0��de amM
�� /) n � ❑ Yes ❑ No
I( I10. wh2l 6 h15 / h¢! ¢ZdCI Sh2f0 O( IIfICf¢52?
If name m remN's E'iRerent Nan Ihat ol app6rant, uMinte bebw.
Name ot mortgagee or mntrarl seDer �/�
city, state. aM LP cade)
Name a1 asvgnee w oNU owner w holder of mortgage
(numDer aM street �Y. sfafe. aM LP code)
Dces appiwaM own yoperty in any oNer
murLLyinlnd'ana? � __
with someone other than spouse,
Is C�e MoPem' in Cuestio^: Mnua�y h5se55tV
❑ Reai aoa�r � ��r �ss�a
n�obae r�o� �ic s
Drawcr NO...�� �........
c�ra no. ...��SS.......
o�mm _ � � � � b�'7 -
I mr aneru Yean Q Yes
❑ No
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