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""� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS I Year
__ : FOR DEDUCTION FROM ASSESSED VALUATION
�• Sta[e Form d3709 (R71 / 6-W)
S,.,. � Presmbed Oy DepaNnerd W Ln�l Govemment Frence
F" e
INSTRUCTIONS: S E P
wm filed with:
To 6e filed in person w by mail with the CountyA Witor or Counry RecoNe� o/ Ne counry where the pioperty is bcated.
Filirg Dates: 1) Real Pmperty: Must �le dunng Na year7or which the detluction is so�ght. Counry AuEimr
2) Mo6de /Manu/actured Homes not assessed as Real PropeRy: Must Ae dunng the fv+eHe (12) month� �^���
6e(ole Mamh 31 of each year the deduclion is sought. a �..ounry Recordu
SeereversesideforadditionalinsWCtionsandqvalificafans. ., GIBSONC � v TOR
App6ant (ownerar conGap 6uyer, see restrjSOOns m reve,rse sda) , �_ A
w�essm vdWe af mal qopercy es a
arrh 1. arrellt yrdr
/1
II �q, what IS his / her ezaU share 01 int[
If name on rem�d is Ci:femft Man Nat o
r��e o� „bn�asee a �a,va« unn
Addtess o1 mortgagee or wntracl uAer
nanber / kgal dewiPtion
� -Iq_3� -/o/ -
appOCant, hMUate Gebv.:
Name of asvgnee or othu ovmer rn hdEer ot mort9age
Oces eppliont own yoperty in any oMer
munry in IMana?
❑ Yes
DeauttiOn appmved'vi the artpunl of.
�_ �_
syramre d co�,�ry nw�� A �
0
xrtlfy er ihe penalty of
I mn ct buver ot Ne ator
No
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se4 uty, sbte.
LP tode)
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nentionea �
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' W Attorney rn by IC 61..
Mdress of aW�a¢� person (number ard stree; cify. stdfe, aM ZIP ca.
-�aa-Od
tt owned wiN somearie other than s-
�jl
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i
00 YyY7
�s unpaiE as M Is ine applinnt Ne sde
kgal w epuitable ownel.+
�� ❑ Yes ❑ No
Ke wtth vAwm
�esDOn:MnuauyASSesseO
'-] amuany assessed
�
�rraNh. tlaY• 1�� �
ie applinnt is a resident of Indiana a�
Date (monN, tlay, yaa�
Date (monN, tlaY• Y��