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M•—^ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou o ns ar
r/` " �'q
a_ _. : FOR DEDUCTION FROM ASSESSED VALUATION
"�� Sta:eFOrmc3709(R17/6-09) Gibso M tgom 201
�� ��• Prescnbetl by DeOarimeN of Local Govemment Finance
File Mark
INSTRUCTIONS:
To be lled in person or by mail. � �� ,�h�
Filing Dates: 7J Real Property: Must be comp/eted and da(ed in fhe calendar year for which the deduction is sought.
Must be /iled wi(h !he County Audi(or or Counry Recorder o/ the counry where (he property is located ry Auditor
on orbelore January 5 o7fhe immedialelysucceeding calendar year_ C o�n[ ewrder
2) Mobite /Manu7acrored Homes no( assessed as Real Property: Mus( �le with the CounryAudilor o7 the
counly where fhe propetly is locafed dunng fhe rtvelve (12J months 6elore March 37 ot each year theG.18$ON COUNTY AU ITOR
deduction is sought. •
See reverse side foi additional instmclions antl aualifiw[ions.
Ap�can� (owirer or tont2ct buyer - see res:rirtions on reverse sitle) -
Paul W. Edwards and Sarah A. Edwards �
Tau�g Disirict Key number / legal desuiplion Record num0er Pa e number
Montgomery 26-17-20-200-004.779-021INW NE 203-12 �O � I ��
� Assessed value W real properry as ol Mortgage / ConUact indebtedness unpaid as of Mortgage / Con'vaG indebtedness unpaid as ot Is Ne applicant the sde
�AWrrh t, currentyear March i, wnent year date of application legal w equiuble aener?
3400.00� 184000.00 ❑� Yes ❑ No
II no, wnat is his f her e*acl s�are of interest? If amed wiN someone oNer lhan spouse. irWiwle wiN whom
If name on rxwE Is CiHerent Ihan lhat of apP���nt, indicate bebxc Is fhe property in Guestion: Mnua0yA55esuC
❑� Real Property ❑ MnualyASSessed
Mobile Home QC 61.1-7)
Name of mottgagee or conUact seller
First Security Bank of Owensboro, Inc. �
AdCress of rtartgagae w wnlract seller (number antl street, ury. sta�e. and ZIP code)
Name ol assignee or olher owner or MICer of mortgage
Address of assignee (number and street, city, stafe, and ZIP code)
Dces applifant ann pmperty in any oNer If yes, what counry? l^fiat Tasing Distria7 Has Nis deduc6on been reQUested on pmperty
wunty in InCiana? ❑ for current year!
Yes No ❑ Yes ❑ No
COUNTY AUUI70R
OeducGOn appro-:eC in Ne amount of:
20 20 _ 20 20 _ 20 20 20 _
Signamre of Counry Audi:or County Date (monfh, day. year)
I/ We certify under the penalry of perjury that the above and foregoing informauon is true and correct and Nat the appliwn, is a residen; of Indiana and
owner / conVact buyer o( the aforementioned property on date lication is filed. -
� Signalure (owners full ama � ' � Date (monfh, dag yea�
�"� 04-19-2011
Full resident atlEress of appliwnt (numher antl sbeet, city, 5(ate, end ZIP code)
70787 W 750 S Owensville, IN 47665
Perwn authonze0 Oy tlury enawted Power of Anorney or by IG G1.1-12-07 Date (mon:h, day, year)
Address ot au;honzed Person (num6eran0 sbeel. ciry, slate, artd ZlPCOtle) I