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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship Year
:_ _� FOR DEDUCTION FROM ASSESSED VALUATION
Sta[e Fortn d3709 (R71 / 6-09)
�' 1 Presaibad by �epartment of Local Govemment Firance
� File Mark
INSTRUCTIONS: �EC �
To 6e filed in erson or 6 mail wifh fhe Coun Audifor or Coun Recorder o/ the coun where !he m �
P Y N b h P PeM is locaf
Filirg Dates: i) Real Property: Must file dunng the year for which the deducfion is sought. Counry Audimr
2) Mo6de /Manu(actured Homes rat assessed as Real Property Mus( rile dunng the fwelve (72) month� ���
belwe MarcA 31 0! each year Ne deduction is sought. ounry Recorder
See reverse side for aCditional insnuctions and qualifrcations. G I BSON C OU NTY AUDITOR
App6 t(owner ormntraU buYer - see 2§ni�'ms w 2ver�e side)
iR•�:^iil!�T
ra. what is his / her e�ct share at interesi?
I - -ooa.o 90 -o�. y
�/ Contrac[ "udebtedness unpaid as of Mortgage I ContraG
airtent year Eate of appfi�ation
If name m recad's ditterent Nan ihat ot aPP�4 trdicate below.
itt
Name of mort�jagee or contract
,�^.��':,.'' =`�3�
mOrtc�aye
cily, state. aM ZIP code)
Adtlress ot assigriee (number antl sfree4 �1: sfete, and ZIP code)
Does applimnl rnvn yOp¢rty in any olner
counry in Intliana? � _ .
20
amcunt oC
20
If owned wiN
COUNTYAUDROR
20 20 20
Caunry
Reco�d number Page number
ao�i stia �
> un7� as o( Is Ihe aPW�t Ne stle
legal w equBade awneR
❑ Yes ❑ No
indkate ritt� Mtiom
Is tl�e P�GenY in Vuestion: MnuaM Pssessed
�tea� ampeny � a.�nua�yassessea
Moh�le Hame (IC 67.
Dra�ti•er \'O..�ll.11.........
Card i\`O. .. �y. a.7 .......
�a�Jl, �i3.�
20 I 20
,,..o,.. d„�
� I I We certify uMer Ue penal f perjury e above and foregoing infortnalion is We and correct arW that ihe applirant is a resident of IrWiana arM
owner I contracl buyer of the aforemention property on date application is filed.
k Sigranre e' reme) Date (rnorah. Cay. y�eah
��'-u0 ' nt ol applirant (rwmbe� and sbeet �y. state, and ZIP cotle)
Person auUrorized Dy Outy exeatetl
person (numDer arid sneet. ury, slale. an0 LPCOde)
Dace (monN, tlay, ysa�