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'°� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Year
_ s FOR DEDUCTION FROM ASSESSED VALUATION
• State Fortn 03709 (R71 / 6-09)
�,�,� � Presaibed Ey De7a�M of laW Gwemment Firance
File Mark
wsrnucnoNS: FEB 1 � ��,�,
b be fited in person or by mail with the CountyAuditor or Counry Recortler o7 Ne county wliera the property is located-
Fiiirg Dates: i) Real Pmperty: Must file durirg fhe year for wliich the deducfion is soughG � Counry Auditnr
2) MabAe / Manufectured Homes not assessed as Real Property Must Ae during the tweNe (12) mor�(',p� ��unry Recorder
6efae March 37 o/each year the deduction is saght. G
v
See 2versa side (oraddiliona(instructbns erMqualificallorys, GIBSON COU — +
eaad
tlan Ihat of aPP��4 inditata Eelmr.
Name W rtmrtgagee or mnttacl seller
AEtlress d mort9agea or mntratl s��
Narna of assiqnee w othv awner or h
e�M sRee4 my, s16te, aM Z/P cotle)
G�nt ovm pnpMy in any oMer
Intliana?
❑ Yes
O�duUOn epprovad In Ne amount
20 � 20
Sig�Lve d Camty Audilcr
���.
�
numCu
O . 1 —(/l.
M0�3g0 / COntrefl
date ol eppfmation
If ox+red with wmeone other ihan spouse.
Is Me P�G�Y in OueYk
❑ Real P`oPe�1Y ❑
Page wmber (/l'�
pd'�j (� 5� /
CQU1�8 OMT12(i
] Yes ❑ No
3� �
�Fiartie�flC Gt.t-i
de)
- g t A� i y, �a�e,2y � -
pzPr�A S�
�' �io- 3aq ry
1UNTY AUOR
20 20 _ 2tl _ N1 _
Caunry I Date (montl+. EaY. Y��
1/ We cert(y urWu Uie penatty of perjury Nat the above and (oregoing infortnation is We and cortect arM Nat Ne applicant is a tesident of IrMiana aM
owner / wntract buyer ot Ne afwementioned property on date applinbon is fileA.
�re (o / � �' . �i / C oate (rrrnrh, aeY. Y�A
o_�'iT� /9 7_— 1 i� I.9
resident
Power dARaney or by
autlror'¢ed person (numDer arM street �Y. s+a�e.
7G3g
o��e c�.,m, mr, re��