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� a�-T"�=�y� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count
Y-,..y = FOR DEDUCTION FROM ASSESSED VALUATION
Sate Fwm a3709 (R77 / 6-09) Gibson
�� + Preurihed by Department ol Local Govemment Finance
INSTRUCTIONS:
To be �led in person oi by mail.
Filing Dates: iJ Real Property: Mus; be cnmpleted and dated in the calendar year for which the deduclion is sought.
Must be �led wifh the CountyAuditor o� County Recorde� of fhe county where fhe property is located
on or 6efore January 5 0l fhe immediately succeeding wlendar year.
2) Mobile / Manulactured Homes not assessed as Real Property: Must file with Ihe CounryAUditor olt6e
county where the propeRy is located dunng the iweNe (72) months before March 37 0/ each year the
deduction is soughL .
See mverse side Ior additional instructions and qualifications.
IApplican� (owner or contract buyer- see res.rictions on reverse sida) �
Greaorv K. Bane and Stacev M. Bane
Tadrg Disinct cn lio
Gibson 26-1836-200-002.443-024�8 26-18-36-200-001.652-024
f vaWe oi real property as
axrrnt year Marrh
00.00 0.00
fro, what is Ivs / her exact share
Johnson � 2013
� CpounryAuditor
N�' 2CguReq�corder
C.'J. M.zB--
Page number
TC�tIVdCi inee�tedness unpaid as of Martgage / GonVacl intlebtedness unpaid as o( Is Ne appliwnt �he sole
curtent year Eale of applicalion 1e3� or equitabie owneR
300,800.00 0 Yes ❑ No
� If owne� with someone other Ihan spouse, intlicare with whwn
If name on record is di9erent ihan that of applipnt, indicate bebxc
Name af rtwrtgagee or mnvact seller
First Security Bank
Address of morigagee or conVaG se0er (number and streef. tiry, state, and ZIP code)
123 S. Green River Road, Evansville, IN 47715
Ad7ress of assignee (number antl sbeet, ril}; state. arM
Dces applicant own property in any otner If yes, whai munry? Whai Taring DisVict?
fnwryinlndana? n � No GibSOn
� Yes
Is Ihe property in questian: Mnualy Asussed
�❑ Real Prooerty ❑ Annually Assessed
Has ihis CeCUCtian been requested on pmperty
for curtent year?
n Yes n No
COUNTY AUDITOR
Daducrion appmved in Ne amoum o`:
20 20 20 20 20 20 20
SignaWre ol CounryAUdimr Coun,y Da;e (monM, Oay, yeaq
I/ We certify under the penalty of perjury that ihe above and foregoing in(ormatlon is [rue and corteci and ihat ihe applicant is a resident of Indiana and
owner I conVact buyer of the aforementioned property on date aoplication is filed.
Signature fowne�s (utl name) �ate (mrnN, dag year)
11I20/2012
Fu0 resitlent addre f plica t(number and 5t2 , ity, 5(ate. an0 ZIP code)
9902 Misty Lane, aubstadt. IN 47639
Parson auNOrizetl by Culy executed Power of Attorney or by IC 61J-12-07 Da[e (month, day, year)
Address of au.honzeC person (number and sireet, ciry, sfate, arM ZIP code)