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-o•..v�o STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
.°i_, . t FOR DEDUCTION FROM ASSESSED VALUATION
�'• � SUte Fwm d3709 (R17 / 6-09)
� Prescnbed by DeparVneni of Local Govemment Finance
INSTRUCTIONS:
To be filed in person or 6y mail.
Filing Dafes: 7J Real Property: Musf be comple(ed and dafed in fhe calendar yearlor which the deduction is sought.
Mus16e filed wifh the County Audiror or County Recordei o/ the counry where the pmperty is locared
on or 6afore January 5 of the immedialely succeeding calenda� year.
2) Mo6ile / Manufactured Homes not assessed as Real Property: Musf file wifh fhe County Auditor o/ the
county wAere Ihe propeRy is located dunng fhe hvelve (72) monfhs before March 31 of each year fhe
deduction is sought.
See reverse side lor additional insfrucGons and qualilcafions.
AppGCant (awner or oonvarx 6uyar - see raurictions on ieverse side)
CHRISTIAN T WALL
1Coun9ry� Auditor
M 1�uRty�corder
PATOKA � 26-12-31-700-000.405-027 � �
Assesetl value W real pmperty as ol Mort9age / Contract iMebtedness unpaid as W Mortgage / Con;raa indeb;edness unpaid as of Is Ne appGcant Ne sde
h'daNi 7. artent year March 1, wrtent year Eate of applicalion legal or equitaWe owneR
80,700 58.200 93,000 ❑� Yes ❑ No
If no, what is his / her exact share o( interest4 If owneE wiN mmeone other ihan spouse, inCiwte with whom
If name on recorC is EiRerem than Iha� o( aDW����• �dicate bebw. Is Ne property in questbn: MnualtyASSe55eC
NICHOLAS S BELOAT ❑� Real Property ❑ AnnuallyAssessed
ne..wie u,...,e nr �> >_:
Name of mortgagee w mnUacl se0er
KIRKSTON MORTGAGE LENDING
AdOress of mortgagee or mnVact se0er (number and sLee4 �'. s+a'e, arM ZIP cotle)
501 CROSS POINTE BLVD EVANSVILLE IN 47715
or o;her owner or holtler oi mortgage
AGdress of assi9nee (number antl street. dry. slare. and ZIP co0e)
Does applicant own property in any
wunry in Indiana? � ..
nas tnrs tleaucem Daen requesteG on prope .ry
for artent yeaR
❑ Ves ❑ No
� COUNNAUDITOR
OeEuction appmveE in Ihe amount of:
20 20 20 _ 20 20 20 _ 20 _
Synature ot CounryAUdimr I Gounry Date (rtanth, day, yeah
I I We certify under the penalry ot perjury that the above antl foregoing infortnation is true and corteci and that [he applicant is a resident of Indiana and
owneN conVact buyer of the aforementioned property on date application is filed.
� SiGnaNre m 5 fu0 name) I Date (rtwnN, tlay, yea�
/�
osiosno>>
Fu0 resident atltlress ot apP ��^� (number ntl slreel, city, stale. and ZlPCOde)
339 W 350 S PRINCETON IN 47670
Person auUwnzeE by duly ezewted Poaer of Atlwney or by IC G7.1-12-0J Date (month, day. yea�
Adtlress ol author¢ed Derson (number aiM sbeet ciry, state, and ZIP coEe)