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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship vear
:•_—
s FOR DEDUCTION FROM ASSESSED VALUATION
• State Fortn A3709 (R71 / 649)
�` ,�,� � Prrsfiibed by Departmen[ of Local Govemment Frence
File Mark
�TRUCTIONS:
To be filed in person w 6y mail wiN the CounryAWitor or County Recoider o7 Ne county whe2 the property is located.
Fitirg Dates: 1) Real Property. Musf �le dun�g tha year for which tha deduction is soughf. nry Aud'rtor
2) Mo6Ae /Manufacfured Hwrres rrot assessed as Real Property Must fi!e dunng the M1vefve (72) months ���
6efo,e Ma�cA 31 o/eacA year fhe deduction is mught. u ecorder
See reversasjde (or adtlitional insbucfions and qualifications. G I B SO N COU NTY AU DITOR
as d
M2iCh 1, aaiMt yPar
tt no. what is h's I her exar�
rumihel / legal
If narne m remE is dilferent than ihat of aPW���. �i`ate �ebw:
Name M rrort8a9ee or mntract selle
,L% /` OA /1
reA W rtprtgagee or mntrad seAet �numbe� and stree4 �y. s+ate.
Name o� assignee w oMU owner w
Address of assignee (numberaMv
cAy, stete. eia ur cooe)
property in any oNer I I( yes.
❑ Yes ❑ No
cno� ecwoved m ure a�,�w�
20 _ N7
itlne W Co�mty Auditw
number � Page rwmb�
�
I az d Mortgage traa uMe6tedness �mpaid as d b ihe appGOnt the sde
Oate oi aDP�� � a eWitade aw�
❑ Yes ❑ No
If wmed vrith someo�re other than spouse. indicate wMh whom
��
Is Me Property in Queslion: MnuaOy AssesseE
�ea� PmPerlY ❑ Mnual�YAsses�ed
hbdle Fiorne OC 6
STEW�2TT J�N�-'�� �
ia— � rSCo ry
� No
couNnaunrro ��A'vs��� ���xt
20 _ � 20 _ � 20 _
Counry
yean
20 _
I I We certify uMer Ne penalry of perjury that ihe above and foregoing infortnation is W e and corte�3 arM that the applinnt is a resident of Indiara aM
oxmer / wntraU buyer of the aForementioned property on date application is filed.
Sig�ture (owner3 hN rame) trdte (monlh. der Y��)
of
and ZIP mtle)
or Gy IC G7.142-0.7
1 I Atldress of aWrorrzed �..on (num6er aM snee4 �Y. sfate,
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rrth, d2Y,