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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Co n _ ow s p Y r
_, ; FOR DEDUCTION FROM ASSESSED VALUATION
Stata FOrtn 43709 (R77/6-09)
,' ,,,. � Pr�aibad by DeP��rtl of Laal GovemmeN Firence t L
File Mark
INSTRUCT70NS: �
To 6e fiied in person or by mail with the CountyAuditw or Counry Recorder o/ the county where the plopeRy is located. �
Fil'mg Dafes: 1) Real Property: Must file dun�g the year lor which the deduction is sought. GIBSQpJ AuEimr
2) Mo6ile / Manufactuled Homes not assessed as Real PropeRy Must fife dunng the fwelve (72J months C� Y q � rytn� �
6efore March 37 of eacA year the deduction is sought. Coun�'tcEtloraer
See reverse side for additional inswcUons and qualifications. p
I Mdirant (owneiA' connaU buyu' fpa reJLiUions an q�ene sifa) n �
�,.�rt,ea�,�,«�r�or -
7, qmM year
m. what is Itis ! her e�aC shara of interesi?
name on mmrtl a tliRerent ihan Nat af aool
legal
Mongage / Contraa indehtedr
Mamh 1, artent year
�G3dQ
Name o( rrortgagee or conVact seller F/�
✓
Address of mortgagce a contraG se0er (number eM sheeL �N: sta:e. aM Z/P cada)
Name ot assignee w ahg owner ar halder ol fmrigage
�a��t �, �ra, a,�z
in eny oNer I(
] Yes ❑ No
. ./ 1 /„/ �LL—
Dr�uction approved in Ne amount oE
20 _
SignaNre of Counb AuGitor
l.9 7-o�y
i az of Mortgage I ContraG inde6tednes
tlate of appfietion
If oxmd wiN someone other ihan spouse.
COUNTY AUDIT(
20 � 20 � 20
Counry
Recortl number
aoo9
��a�� �s
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drczte with wiwm
numCel
3i�
Y� u No
Is ihe property in purstion: MnuaOy Assessed
�'F2eal Property ❑ MnuallyASSe„sed
-F,o�S�! K. �°W� '
�0..°��•........
pl•a��•cr i .
33 �Z9 ....... o�
Card /��Q��• ';�ux� ��lb'-�•°� �
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p- � �_
Date (month. daY Y��
20
I/ We certify uMV the penalry of perjury that Ne above and (oregoing information is true and cortec[ and that the applinnt is a resident of IfMiare arW
owner I contraci buyer of the aforemerrtioned property on date applicatlon is filetl.
(number aM stree4 �N, �te. antl Z1P aotle)
'f0 W �Avj;J7q�
ed Power of AttomeY a M IC 61.1-12-0.7
Ptltlress ot autlroraed person (number arM stree(. Uy. state, and LP mde) . I�