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d�4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS � Count
�t_._ .:y i FOR DEDUCTION FROM ASSESSED VALUATION
Sate Portn »3709 (Rtl / 6-09) Gi65on
Prewibed by �epartment of Local Govemment Finance
WSTRUCTIONS:
To 6e filetl in person or by mail.
Filing Daies: 7J Real Property: Musi be completed and dated in the calendar year /or which Ihe deduction is sought.
Musf be filed with fhe CounyAuditor o� Counry Recorder o/ the county where the property is located DE
on oi before January 5 oJ the immediately succeeding calendar yea�.
2) Mobile /Manufactured Homes not assessed as Real Property: Must (le wifh Ihe County Auditor o/ the C
county �vhere the property is located dunng the hveNe (72) months before 1'darch 31 ot eacA year the
deduction is sought.
See reverse side foradditional insfructions and qualifications. GIBSON
IApqicant (owner or contract 6uyer see resmctions rn ieverse side�
Dustin M. Fishback and Rebecca A. Fishback
'� 7axirg DisWc; Key numbeN legal desafptlon 6—/'] -Z - z OQ Q.�J Q/ / � a I Rem
CiIbSO - - - . -
1
I�� 13
Township
Montgomery
File az
Year
2012
2��FauntyAUdi:or
UII
Caunry Remrder
, Assessed value d reai poperty a f Mortgage / Convaa indebtedness unpaid as of Mortgage / Coniraa indebtedness unpaid as of Is �he applicam ihe sde
' Mardi 1, wnent year MarM 1, curtent year date of appliwtion legal or equPable owner?
�1.600.00 311,100.00 162,940.00 ❑� Yes ❑ No
.. io, v:hat is his I her exact shara of interest? � If owned wi:h wmeone other �han spouse, inCica:e with whom
name on record is CiBerent Nan Na[ of applicant, indicate bzbv.:
Name of martgagee or mn•✓act se0er
Hallmark Home Mortgage, LLC
Add2ss of rtartgagee or contrad se0er (num5er and street. ciry, s.ate. and ZIP code)
7421 Coldwater Road, Fort Wayne, IN 46825
Name o{ assignee or o;her ovmer or hdder of mortgage
antl streef. uty, state. an0 ZIP code)
Dces appiicant own property in any �
counry in Indiana?
❑ Yes
No
munry? � NTat Tadng Disbic:?
Is the pmperty in questian: MnualtyPSSessed
❑! Real Property ❑ MnuallyASSessed
Has ihis tletluciion been requestetl m property
forcurtentyeaR � „ �
COUNTY AUDITOR
Dttluction approved in Ne amount o::
20 20 _ 20 20 20 20 20 _
Sigr,aWre o� Coun,yAudibr Couny Date (mcnth. tlay, year)
T•
I/ We ceNfy under :he penalty of perj that the abo nd foregoing iniormation is true and cortect and that the applicant is a resident of Indiana and
owner / conVact buyer of the aforementioned propert n date application is filed.
°'qn �re neYS fu0name) Date (month. tlay, yeaq
� 12I7912011
� Fu0 resident aCCress of aoG���nt (number antl street, cdy, slafe, and ZIP code)
7874 Willowbrook, Owensville, IN 47665
Person aulhonzed by tluty exawted Power of Attomey or by IC F7.1-12-07 I Date (month, tlay, yeaq
Address of authorized person (numberand sfreet, ciry. state, aM ZIP code)