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ey ,��: STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
-E�; FOR DEDUCTION FROM ASSESSED VALUATION
Sute Forzn:3709 (ftit / 699)
��' Prescribetl Oy Department of Local Govemment Pinance
INSTRUCTIONS:
Count Township Year
Gibso F� ranch Ot
de ark
To be filetl in person or by mail. F9 V L�q'"1'� Z �� �
Filing Dates: 7) Real Pmperty Must be complefed and dafed in the calendar year7o� which (he deducfion is sougbt � County Autliror
Musf be frled wiN (he County Autlitor orCounty Reco�der o/ the county where the properfy is loca�ed
on or 6elore January 5 0( Ihe immetliatefy succeedirg calentlar yeac C• • ecorder
2) Mobile / Manu7aduretl Homes not assessed as Real Propetty: Must /ile wiM Ihe CounryAuditor o! fhe
counry where the property is located dunng the nvelve (72) mon�hs belore March 37 of each year the
deduc�ion is sought. GIBSON COUNTY AU ITOR
See �everse side 7or atldifional insfruc6ons and quali/ications.
Applirant (oNner or contrdctGUyer - see resfriclions on reverse side)
Christopher R. and Kendra N. Collins
Taxing DisMct Key number / legal Cescriptbn Reoo�nOumber Paqe number
FT. Branch 26-1&19-203-007242-026IPt S 1I2 NE 1/4 19-3-10 AKA Tract 21 Indian jd� D
Assessed value N real propeM as ol Mortga9e / Cmiraa indebtedness unpaid as W MMgage! Convact indebtedness unpaid as of Is �he appicam t�e sde
�A7arrh 1, cvrtent year hlarch L airtent year date ot aOW��� legal or eQUilaWa uxner?
787800.00 245100.00 ❑O 1'es ❑ No
tl no. what is his / her exact share of interest? If oxned �WN someone other than spouse, iMinte wit� whom
II name rn record is tli°erent than lhat d appliwnl. indicate Deb+.�: Is Ne property in quesUOn: MnualtyAssessed
❑� Real Pmper[y ❑ MnuaOy Pssessed
Mobile Home pC 6-1.7d)
Name o( mwtgagee w cantact seiRr
Old Nalional Bank
Mdress of rtwrtgagee or mnUaa setler (number and srceet, ary. state, antl ZlPcode)
kame of ass'ryree or oNer owner w holder of moM1gage
Aedress of assignee (number and s:�ee+. u1y stare, anC ZIP code)
Dues applicant a«n pmpeny in any oiher II yes, what wunty? What Tacing Dislnct? Has �his Eeducuon been requesteC rn propeny
mwty in Intliana? ,_,( tor aRem yeaR Y05 ry No
p[J Yes ❑ No �,� f ❑ NJ
COUNTY AUOITOR
Oeduction appmveC in Ne amount of:
20 20 20 20 20 20 _ 20
Sge�awre a/ Counry AuCitw Counry Date (mrnlh, tlay. year)
I/ We cer4fy under Ihe penalry of perjury that the above antl foregoing intortnafion is true and correa and that the applicant is a residen� of iMiana and
ov:ner I wntract buyer of the aforemenDOned property on date application is fileG.
� Signawr o- er :Wlna Date (mm:h, day. yea�
os�sono»
Full resitlent adress of appfcaN (numDer arb sheet, cify 5are, anC LPCOde)
171 E 780 S Fort Branch, IN 47648
Person aufhonzed by duly evecutetl Pv.ver of Attorney w oy IC 61.1-12-0.7 Date (monN. day. yea�
AECress ol auVqrized person (number antl 5reef. ary. state, arM ZfP cn0e)