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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coum
__ s FOR DEDUCTION FROM ASSESSED VALUATION
� Stata Fortn C3709 (R71 I6-09)
�' y�. 1 Pmsaibed by DepartmeM of Lacal Govemme�ri Finarce
INSTRUCTIONS:
To 6e (ded in person w by mail with the CounryAutlitor or Counry RecoNer o/ the counry where the property is located.
Fifirg Dates: 7) Real Property: Must file durrrg the year for which the deUuclion is sought
2) Mo6Re / Manufactumd Homes rwt assessed as Real Properly Must file dunng the fwelve (72) months
before March 37 0( each year the deduction a so1ght.
See 2verse side for addifional instnicGons arM qualdreatans.
A7P�9p(ox+ierorgontrpCDuyer- reuarsesde)
rre� voa«ir as m
Y�
It n2rtie on
Name of rtqltgagee or mntraG se�er
Addless W mortgagce ar mntratl
Year
E�j2 ��n,a,�d���
❑ Counry Recordes
GIBSON COUrv I Y hUDITOR
Eer /� C/� o V— OV �. �./ / �— Va' Remrd rw � P num �
Mor�qage / Contraa Intlebted�ress unpaid as of Mongage / ContraR i(WebieCness wpaitl as d Is Vre eppliranf the sde
Mamh 7, wrrent yenr tlate o( appGration W legal ar epudade ox1wY1
/ �D� ❑ Yes ❑ No
If owned wiN someorre dher ihan spouse. Ir�dirate with whom
�l trWiote Eebw. Is O�O�Y in Vursoon: Mn�eDY AssesseE
Real Property ❑ Armually Assessed
, 0.lodle Fbme (IC 61.1-7
owner w holEer of rtprt9age
�er and stree4 M: s+ete, and
Dces apptirvnt own propeM1y in any oNer
munry in Indiana?
❑ Yes ❑ No
Deducfion app�m�ed in Ne amount of:
�
synawfe ot Camb n,�artor
zo
crty, sbta. ard LP code)
If yes. what mur
D1�1,V��- 1�r�...ab�.D........
Cal'C� �0. ....�-•.1�.......
p �� i�� .�
'uctim been reVUested m P�Y
=a(.+ r� .. r� .
0
I I We ceNfy under Ihe penalry of perjury thai the a6ove and foregoing informalion is trve and correct arW that Me applinnt is a resident of Indiana arM
owner ! mntraU buyer of the afwemeniioned property on date apd��n is filed.
YiaWre (4wne/s hA�W^e) � Date (monN, daY. Y�
�
MCress of authoraed person (number arM sbaet, rily, state, antl ZlPCOde)
Date (monfh. EaY. Yee�