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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count Township vear
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��a_..., � FOR DEDUCTION FROM ASSESSED VALUATION.
� S�a�e Fortn a3709 (Rn 16�09) Gibson Johnson 2012
��, Presaibed by OeOartment of Local Govemment Finance
INS7RUCTIONS:
To be �led in person o� 6y mail.
Filing Da(es: i) Real Pmperty: Musf be cnmpleted and dafetl in the calendar year for which the deduction is sought.
Musi 6e filed vrtfn the Counry Audiro� or County RecorUer ol the county where the p�operty is located
on or before January 5 of fhe immediately succeeding cafendar year.
2J Mobils /Manu/acNred Homes not assessed as Real P�operty Must file with Ihe CountyAuditoi o( Ihe
rnunry where the propeRy is located dunng the tvielve (12J months before March 37 of each year [he
deducfion is sought.
See reverse side tor additional insVUCtions and qualifications.
Applican� (o�mer or crontract buyer- see 2sficfions on reverse side)
Kevin W. and Laurie A. Miller �
Ta<irg Distnct Key num6er / le9al descnpUOn
Gibson 2&78-34�00-002.242-024
�V 66dhtYy�f��rder
Ktsessed value o1 real poperty as o( Mortgage / Contract intlebtedness unpaiC as of Mortgage I ConVacl indebtedness unpaiC as of Is �he epplicant Ihe sole
Marrh 1, arrent year March 1, curtent year Cate of application �e9al or equilable wmeR
34,700.00 153.000.00 175,000.00 ❑� Yes ❑ No
If rro, what is his / her eract share of interest? I If ownetl vnN someone oNer Nan spouse, in0icate with wfiom
on remM is di9erent Nan Nat ot applicant,
Name of rtartgagee or mnVaU uller -
First Security Bank of Owensboro
Mdress o/ rtarlgagee or mnUact seller (number and slreet rify, state.
123 S. Green River Road, Evansville, IN 47715
Name of assiqnee or other owner or
oi assignee (number and streeL rity, state. antl ZIP code)
Oaes applimnt own oroperty in any oNer
counry in Indana? � ❑
Yes
D_tluclion apOroveE in the amouni of:
No
20 _ � 20 I 20
Signature ol
munry? I WhatTadng Distntt?
COUNTYAUDROR
20 20 _
� Coun.y
Is che property in question: Mnualy Auessed
�❑ Real Property ❑ Mnually Assessed
Mo61e Home fIC 6-t.t
; tttis tletluC,ion been requested on property
cuneniyear? ❑ No
n Yes
20 _ � 20
year)
i I We certify under the penalry of perjury that ihe above and foregoing information is true and covect and that lhe applicant is a resident of Indiana and
owner! conVact buyer of the aforemenooned pmperty on date application is filed.
Signamr (owne�s tuu name) Dare (monN. day, yea�
�� �� �1 . �,V.�_ . 11173/2012
Pu0 resitlent address af appliwnt (number and street. cdy, state. entl ZIP code)
2824 W. Soybean Lane, FoR Branch, IN 47648
Person aultwrized by Euty ezecutetl ?ower ot Attomey or by IC 6-L142-0] � Da:e (mcnth, day, year)
of au',horized person (number antl sbeet, city, state, antl
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