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a• .�o STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count Township � Year
d/....
ii._-,. 1 FOR DEDUCTION FROM ASSESSED VALUATION
�� State Form -3709 (R11 / G-09)
S Gibson Johnson
� Prescnbed by Department of Local Govemment Finance
File Mark
INSTRUCTIONS:
To 6e filed in person or by mail. Fo`m th.
Filing Dates: f) Real Property: Must be complered and dafed in fhe calendar year7or which (he detluction is s g t.�
Must 6e (iled with fhe Counry Audiror or Counry Recorder ol the county where the pmperty is ocate o ry rtor
on or before January 5 oI(he immediately succeeding calendar year. Coun ecorder
2) Mo6ile /Manufactured Homes nof assessed as Real PropeRy Musf file wifh fhe CountyAuditoi oJfh !�
county where 1he property is located dunng !he nvelve (12) monNS before March 37 0( each yeai th�El.
deducfion is sought. .
See reverse side for addiiional instrucfions and qualificafions. �� J.
Applicant (owne� w cnntraU buyer � see resLicYions on rererse ske)
Oscar E. and Jessica D. Ross GIBSO
Tadng DistriG Key numCer/ Iegal tlesmpibn Recortl num r number
Johnson Township 2E22-72-300-002.127-024 / Pt NW SW 12�-11 ao�a (�%
Pssessed wlue W real pmperty as ol Mortgage / Convact iMebtetlness unpaitl as W Mongage / ConVact indebtadness unpaid as of Is Ne appliwnt Ne sde
hlarth 1, anent year March 1, cunent year date ot applifation lagal or equitaWe amaR
5203.300.00 ❑� Yes ❑ No
It no, whal is �is / her ezact s�are at interest? If owned vnth someone other lhan spouse, inaiwte wlih whom
II name on record is Ei.Rerent Nan Nat of a00hw^C i�dirate bebw Is Na pmperty in 9uestbn: MnuaOy Assessetl
❑� Real Property Q MnuallyASSessed
Mobile Home QC 61.7-7)
Name ot mortgagee or conL•ad seAer
Atltlress of rtwrtgagee or contrac� seller (numDerantl sfreet, ciry, sfate. aMZlPcode)
Heritage Federel Credii Union
Name ol assignee or oNer owner or IwMer of nwrtgage
5388 Old State Road 66, Newburgh, IN 47630
AECress of assi9nee (numDer and streef, dry, stafe, antl ZIP code)
Does applicant own property in any oNer It yes. what wunry? lMiat Tazing DisMCO Has Nis tletluctlon Ceen requesled on Omperty
counry in Intliana? O No tor current yean � Yes ❑ No
❑ Yes
COUNTY AUDITOR
DeEUdion aD W�'+� ��e amoun� of:
20 20 20 20 _ 20 20 _ 20 _
Sgna;ure of CounryAUtlitor Counry Date (monN, day. yeaQ
C-
I I We certi(y under ihe penalry erjury that the a ve and foregoing information is Vue and wrteci and that the applicant is a resident af Indiana antl
owner / conVact buyer of lhe a rementioned pmp rty on date application is filed.
Sgnature (ownefs IWI name) Date (monM, day, year)
/ � � �
FuA resiEent address of applica t(num ntl slreef. ciry, sta(e, arM ZIP code)
77562 S. 150 w. Haubstadt, IN 47639
Person auNOrized by duly executed Power ol Attomey or Dy IC 61.142-07 Date (monfH. day, yea�
ACtlress ot autha¢ad person (number aM sneet, ciry, slate. and Z/P code)