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_'°� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coum
FOR DEDUCTION FROM ASSESSED VALUATION
• Stata Fwm 43709 (R71 / 6-09)
� f PresaiEetl by DeGartmeM M lorvl Gavemment Fumnce � �
INSTRUCTIONS: J
b be �ed in person or by mail with the CountyAuditor or Counry Recorder o� the county where the property is located.
Fitirg Dates: 7J Real Property: Must Ne during the }rear for which Ihe deduction is saught
2) Mo6de / Manufectured Homes rat assessed as Real PropeAy Mus! file during the tweNe (12) months
before March 37 0! each yaar the deduction is sought. �
See 2verse side for additionel inslrucNons and qualrfications.
AeoG�iat fowier ormNaC 6uver- see�85fri�ons on Rverse SiCal
AssesseO raNe af ie�l P�P�Y %� �
Ma�ch 1. a+iv� y a�I
n no. what b tirs i rier erxt share o
:r na�e m rem�e s cm�� wan n
Name m rtartgagee ar
Md�s d rt�o�qagee
-��/� O.J'-QUO.,J�4�-aG%
Maryage/ Contract inCebtedn�s unpaid as W MMgaqa I Can�'uc
Mart3� t. artent Y� .�-. _ 00 tlate o/ appGmtion �
aTy: ata�,
Name ot atignee w oNer awner w haldv d mxtgage
AECress of assignae (num6er entl atree4 �1: stafe, end Z/P code)
Dces ePplipnt pm propriy in any oNer It yns. what mui
oounryminEana? I�'1 .,__ I-1 .�_ �'-'
�_ I p— I 20—
��� � �,a ��
I/ We cerufy uiWer the penalry of perjury that the a
owner / wntract buyer ot the a(orementioned prop
Sip�anue(owne/sNO�me) '
saneorre
�
Mark
F CGpu`2�,m�
1 Counry RewNer
GIBSON COUNTY AUDITOR
Recortl numec Pa9e �wm6Pi
o?o0 4 �/ �a 3
btedness unOaW a d Is the ePW�t the sde
� legal a eQUitade owiu(1
❑ Yes ❑ No
s , indimta w%h vArom
�Is pmpeM1y in puatim: MnueOy AssrsseE
Real RoPeM1Y ❑ Mnual�YAssessed . . .
m praprny
❑ No
Dra►ver 1\'0....aCC�(�•.
.. ro— 2°—
Card n*p. .
..!.Y.�.�.. ���.�Y,��
� �� 1�J32 - C.) D '•••••• e applirant is a residem of Ind'gna and
on date eHr•_-..
Full yddent adtlmss d aR�rani (numDer erM streeC dN. slste, aM ZIP mde)
111� - Z Nd
a� aw��a ey awr �ea,�ea a� wnnm+er « ey ic �i.�-u-0.�
Address ot authorrsed pcsm (numberariC sbeeL Nh: stale, entl LP mde)
oa�e c�m.