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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS C� p Year
, : FOR DEDUCTION FROM ASSESSED VALUATION
� Sta[eFwmd3709(R71/6-09) C P S ZO��
4' t Presaibed 6y OepartrtreM af Loml Govemrtrenl Fnance J
,«.
fNSTRUCTIONS: C ���
To 6e filed in F0`m �� �
person w 6y mail wiN the CountyAud"ROr or Counry Recorder o! the counry where the properry is located. AU DITOR
Filing Dates: 7) Real Pmperty: Must file dunng the year for which the deduction is sought GIBSO CO J�T�unty Auditnr
2J Mobile / Manufactured Homes not assessed as Real Property: Must file dunng Me 1weNe (72) months
before Malch 37 0/ each year the deduction is srought ❑ County Recorder
See reverse siQe for addifional insf/uctions and qualificatans.
AppG t o aroontra buyer-see onre �rsesitle)
°f-
1 Key fwmher / legal drsoiption R¢mltl number Pape numbrr
� Llm-� / ,� / -7_ 7 _ //_ _ 7 n�, -�'Y-rs /�/7 i).� U / l �/ � !i �-f
� v�e ar � propery az
i 1. anent year
what is h's 1 Mr euG share
tl fwne m remtl a EiRera�t Nan Ihat ol applNant, trMitate Debw.
Name m rtqrt�agce p conbact 5eqer
Name of assignee or
�'
aa iMebtetlness unpaiC az d I Mortgape / Convap
year date of appObtion
shee4 �fi'. sbte.
(number ard street, dry, slate, and ZIP code)
any oNer � 1f yes. what count�/? � VJhal Tadfg Distritl?
20 � 20
Sig�uda/eq�f CounbAUdiNr
` -� �
I/ We certify under the penal
owner / conVad buyer of the
�-�,�/ �wUS
�thwrzed Gy dWy esecuted Power of
Der`+ai
�_
that th a �
ned pr rty
VV
ee�, firy, s7are.
�
unPaid as d is Ihe aVdir�ani Ne sde
legal w epuitade oxneR
❑ Yes ❑ No
sDouse.
PbGeM T G�IE8i1N1: MfIl13M il�C�
�I PraP�Y ❑ �Y �
Mnhy �y,.�_ ......
FAuQuN� ��N��
�O L �
��'NIO�i
. ' —_ , .
20 20
❑ ves ❑ No
p
e and foregoing information is we and cortect arW Mat the applipnt is a resident of IrWiana afM
on date appiiration is filed.
or by IC 61.1-12�7
Date (rnonth, day, �eafj
IJ