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^'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
7r" :
s FOR DEDUCTION FROM ASSESSED VALUATION
• Sfate Form 43709 (R11 / 6-09)
�,�,� P�esaiEeG M OePMmertl af Loml GorernmeM F�nce
File Mark
wsraucnoNS: I
To be (led in person w by mail with fhe County Auditor or Counry Recwder o! the county where the property is located. `�
Filing Dates: i) Real PmpeRy: Musf file durirg the year /or which fha deduclion is soughl. nry Auditor
2) Mo6ile /Manufactumd Homes rat assessed as Real PropeAy: Must h7e dunrrg the fwelve (12) months ���
before March 37 of each year the deduclion is srought. u Remrd<r
See reverse side ta edditional instructions arM qualificatpns. GI BSON COU NTY AUDITOR
Anofiranl lowner or mnbarl bwer- 5ae re.s(ii �lions m rerxrm siiel
Oi� Key rwmGer / legal desuiption -� ^��� Record numb� Pag�umDer �
_a� o� 000. a� o
e0 rdhc d rrdl popeny as W MoKqage / Contract irbehteEness unpaid az of Mortgage / Cmiract mdebtedness unpaid as of is ihe eppfimrt tM sde
i, ameni �ear Memh 7, airtent ynar tlate of appGfation legal w equBade owrce/?
(�p ❑ Yes ❑ No
rhal's his I her e�d share of intemst? tt awned witA mmeone Nhu Ihan spouse. mdrate with wMm
Name of mwigagee w mntraU seller
of mptgageP w mntraG se0er (number end sVeel, cdy, state. aM ZIP code)
Name ol assi�ee w oNU owner or
�re.
Iimnt own yoperty in any otner
IMana? ❑ Yes
❑ No
app�oved'm Ure arznunt oF.
20 I 20 �i / �
l�I
s�q�c�rewco�mb w��w
I I We certify under the q
owner I contrad buyer of
FW reSiCenl addrass
perjury Nat
If ye5, what �
20
COUNTY
20
and foregning infortnalion is�
n date applicalion is filed.
imDer arM Sbe¢t. My. SfatB. end ZIP mtle)
�o�n S{ Sond✓�/�e
Power of Mwney or by IC G7.1-12-0.7
Adtlress of aulharrzed persa� (number aM sbeet rily, slare, antl
�Is -C�.re(� p�operry in Question: MnuaDy PssessM
,� ^eal RoPeM � tvmua�y Assessed
fm ameN yeaR
��P�Y
Yes ❑ No
F?vaa�-�s, m�rz�y =
II -31a5
a and
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Da�e (ma+th, d2Y,1'�e�