HomeMy WebLinkAboutMortgage_Pemberton"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
FOR DEDUCTION FROM ASSESSED VALUATION
� • State Fortn 63709 (R71 / 6-09)
�,w � P�esoiEed by Oepartmerrt af Lnml Gmemmem F�ance
�'NSTRUCTIONS: �
To 6e fiied in person w 6y mail with the CounryAUd�dor or Counry RecoNer of tAe county wheie the pioperty is located.
Filirg Dates: 1) Real Pmperty: Must file dumg the year Por which the deduclion is wught.
2) Mobile / Manulactured hbmes not assessed as Real Property Must fi7e d�nng the M1veNe (72) months
betwe March 37 of each year the deduction is sought.
See reverse side 7or additional insVUCtions and qualfications.
0v1iNV Auditor
LuIL"
Counry Recordef
AD�"� °f °" �� � GIBSON COUNTY q(J TOR
Ta�dng UstriY rvmDer /�pal desaiplim _ _ � Recdd ryry�er Page n
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Assessed vahce af real Wapelty a d Mortgape / Contraa'vde6tedness unpaitl as of • Mortgage I Contract inEe tedness unpaiE as ot Is Me eppfrant the sde
Me'rh t. tlr�mt year Martl� 1. Cate ot aOP�� kgal W eQUitable oxne(1
❑ Yes ❑ No
II ro. what is his / her exaa share of intemst? If ownad with somearre other Ihan spouse. indirate wM whan
II name m remd ig tliBerent Nan Nat of appGmn4 �ditate 6eb�r.
Name of mortgagee v conuact seller
AAdtess oi rtnrtgagee w mntraU se0er (nurti0er aM stree4 �: state, aM ZIP code)
Name W assv3nee or oNer owner or �ol�er M mortgage
AdCress ot assignee (number aM 5treeS my. sfa+e, aM ZIF \
Oces applifam ovm pope�ty in any oNer I If ye
munry in Inda�?
❑ Yes ❑ No
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Persm auNOirzeA Dy dWy ezeai;etl Power of AtlomeY a dY IC 61.1-12-0.7
Pddress o( auNp'sed person (number aM sbee; ri(y, slate, an0 LP cotle)
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Is Ihe praperty in vuesYqn: Mnuely Pss¢sed
� Real Ploperty Q Fvmually Assessed
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feCUflion Oeen reVUesteE an proprny
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infortnation is W e and cortect and that the applican[ is a resident of Iridiana and
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Date (monN. daY• Yaa�)