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"^� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS o
__ , FOR DEDUCTION FROM ASSESSED VALUATION
� � Slata Fofm C3709IR71 / 609)
,,.,� P�esaibed by OePM�� W Lod GoremmeN Fuunce �
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INSTR!/CT10NS: GIBSON COUNTY
b be filed in person or by mad with fhe CounfyAuditor or Counry Recoider o/ the co�nry where the property is located.
Fif'ng Dates: 1) Real Property: Must file durrng fhe year for wliich the deduction is sought.
2) Afo6Be / Manuleduled Homes rwt assessed as Real Properfy Must h7e dunrg the tweNe (72J moriths
be(ae March 31 0/ each year the deduction is sought.
See reverse side Por adtlitional instructions and qualificafions.
AnoNant (owrier atsnbaUbwer - see ra9rirmns m reverse v0e1
nimber / le9al
�rapie cf mal PoOertY as d
1, wmLL year
rc ra, what Ls t� / Irer exaG sliare ol
,tt name m 2mN a dAferent Nan M
/ Cantraa ud�tetlness unoaidas d
mortgagee or mntracl seUer
d rtartgagee ar contraa srder (number end sveeC �Y. smm. eM LP code)
af assignee w othe� ownu or halder of fmrtgage
naa�ass o� asv9�ee tnumoarena sueec m3: seie,
amaum at
0
.'"'Fr ile Mark
V
Counry Audimr
Counry Recorder
nnumber Page rwmCu
%
as d Is �he ePP�^t tlx 5de
kgal a epuilaWe ameR
❑ Yes ❑ No
spouse. rt�arate v�m �vnan
�I tl�e poperty in puestion: MnueAy Assessed
� RnPertY ❑ %vmually As�ed
- _ — ' ��,f,(?........
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Ca,.� �o. ..� � �-
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COUNTYAUOROR �1� �
�
20 20 _ 20 20 2b _ 20 _ 20
uianae d CamN AWimr Counry Date (nmth, daY• Y'��
1! We certify under Ne penatty of perjury that the above and foregoing infortnalion is true and correct arW Nat the appiirant is a resident of InAiana arW
owner / contract buyer of �he aforemert[ioned property on date applintion is filed.
--%i( _/% firo naqme) /J oate (nmrh.1 dIeY. YgeA
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Oy IC 61.
P4tlmss of aWwmed 0�
Date (rtmth. daY. Y��