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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Towns i Year
�_ : FOR DEDUCTION FROM ASSESSED VALUATION
n State Fo�m C3709 (R71 / 609)
�' P�esmbed Dy DepartmeM of loral Govemrtrenl Friarre
� File Mark
wsrRUCnoNS: � E C
b be filed in person w by maif with [he CounryAUditor o� Counry Recnlder of the county where the property is locat
Fr7ing Dates: 7) Real Property: Must file dunng the year for whiGt the deduction i5 sought. Counry Auditor
2) Mo6He / Manufactured Homes not assessed as Real Pmperty: Must file dunng fAe tweHe (12) month� ���
6efore March 31 of each year the deducGon is sought. unty Recorder
See reverse side foradditional instrucfions and quali�cations. GIBSON COUNTY A
Aoofxant,idwner w mnbaG Duve�- sifel
Ta�d Dis �U "KeynumEa/legaldesaiption
�aon� - 3 - 3 -�oo - oo/.
Assessed value d real pmperty as d ge / Contract ind�teEness unpaid as of
Ma� i. am�n11'� 7, alrte�rt year
It no. what ts h'a / her exacl shafe ol intercst? If awm
Ii name on remN is dMerent Nan Nat of appbran4 mdicate be�ow:
Mame of nrutgagee «m„ract sel�er n �'.�— ^. .7 �
(J v— .CJ� _ . (�L .
ALdress of nnrt9agee w contract seAer (num6ei and saee4 ciry. sfa�.
�� o� �g�� � �,� �e� o� ��
Atltlress o1 assignee (number aM afree4
Dces aPplkant ovm pnperty in any other
counry in InCmria?
❑ Yes
Deduclion apycrved in �he amount oE
zo zo_
Sig�anne U Caa:b Auattw 1_
sfete, a� [/F' catle)
If y�s, what �s
I No
� �
I/ We certify under 1he penalry ot peifury that
owner I contracl buyer of the aforementioned
ciry, stare,
Pn�son
e ai
on�
MCress of auUiavEd person (number aM stree4 �: ��e. aM LP oode)
o- a a,
�
Ihan sq
Reco�d number Paga number
.ZO .�o� � %
unpaiG as W Is the aPdionl Me sole
legal or equita6le owneR
n Y� ❑ No
Questbn:MnuaOyAsseSSCE
ry ❑ArmuallyAssessed
anow� r� nc ��.
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� UdIC �?IMii�. U'•1. �88�i
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