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"�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS C u s vear
__ .• FOR DEDUCTION FROM ASSESSED VALUATION
• � State Form 43709 (R77 / bO9)
S,,,, � Prewibed by Deparlment of l.ocal Govemment Firwice
INSTRUCTIONS:
DEC 3 F�e
To be fiied in person w by mail wifh the CountyAuditor or Counry Recnrder oI fhe county where the pioperty is located. F� �� ��
Filing Dates: 1) Real Property Must !le during fhe year (o� which the tleduction is sought. Coun Audimr
2) Mo6Be / Manufactu2d Homes rro1 assessed as Real Prt�perty: Mus! fi!e dunrg the twelve (72) rtwnt ry
6efore March 31 07 each year the deduction is sovght County Recorder
GIBSON CO
See re rse side lor addilional inshuctions and qual�cations.
App! (owner bcontraU buye� see ieSMctionc m reimrse sitle) ��� � / �
L�.a�- Y� -./ � ti _„'.
Key number / legal EEwipCOn (/ � RedQrtl^� Eer Page num
�'"� � 3-I -loo-ool. S`Jv- ad�� v
i real property as d Mort�age / Contraa'vdebte0ness unpaid az of Mongage I ContraG cMebtedrress unpaid as of Is Ne appGCant Me sde
year Martl� 7, ^a�rtent year tlate o( appGmtian legal or equilable wme(.�
�c �/7 n D � ❑ Yes ❑ No
��=L�1
Name oi mongagea «convact selle�
Address of rtnrtgagee or mntraa
Nama W assignea w dher ownet
Mtlress
Ooes epplimnt ovm property in any oNer
tounry in IMaria? ❑ Yes
Deductlon approvad in ihe amount oF.
�
�nanne U Caunh Audimr
1/ We certify urWer �
ovmer / contract buYei
fcanL'o�dirate Delav.'
� � h /
hel aM sLee4 ciN. sfate. aM LP code)
nqrtgage
sfefe, antl Z/P catle)
If yes. whac munty?
I No
20 _ � 20 _ � 20
someorre other Ihan spouse.
What Tanfg Distr'xY7
±i�7
ProVe+b in QueStion: Mtwa%AssessM
� a�oaertv ❑ n�muany assessed
Moble Flmie fIC 6
Has Nis tleEUC6m Eeen reGUesleO m P�Y
ror wrtent yeaR ❑ I
❑ Yes
Fi�.
Date
20
penalty of perjury th the ahove arW (oregoing in(ortnation is We and cortect arW Nat Ne applican[ is a resident of Indiana arM
of Ne atoremention property on date application is filed.
I i /1.. Date (rtmfi. daY. Y��
tity, 51ate, eM
o� (�w. eey, r��
/ddress of aWia'vEd persa� (numbereM sbre; rity, state, anO LP code)