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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship Year
_ FOR DEDUCTION FROM ASSESSED�/Ai�A�lO� T
State Fortn 43709IR71 / 6-09) p°I �� gl
, f Presfribed by DepartmeM of Loral Govemmelrt Flflance �
�µ File Mark
�STRUCTIONS: nr.T � .�n''
k 6e filed in person or by mai/ with the CounyAutliror or County Recorder�a��e ty�ere the pmperty is located. F� ��
ftiirg Dates: 1J Real P�opeity: Musf file during the year for whirh (he dedy4liq��n " �unry Auditor
2) Mo6i7e / Manufactmed Hortres nof assessed as Real Properfy������ ' Vthe tweHe (72J months
6e/ore MarcA 31 oleach year the deducfion is soughG Counry Remrder
Sg�versesideloradd'tionalinstnrctionsandpuali�catiqns. GIBSODYCOUNTYAUDITOR
YmalpfapMya
Y�
Ns I her eract share OI interest?
�/ renie m mmrd ¢ SAfuent than that W appficant, i�Wirate below.
rlame a�rtg�ee or m,raa snler
Add2ss of mort9a9� w mntraG seA¢r (numoer antl sLee4 uN• stafi.
(numEer aM svee4 ary. s+ete. and Z/P code)
Dces appfiram a.m paperty in any oNer I If yes,
mun�y � i�amw� ❑ ves
❑ No
20 _
Sigrenrte ot Caunb AuAitor
20 I 20 I 20
eDP��
.w.��. . ��..L � � OL
T Ov
as of �s me evd'�,t me sde
legal or epuitaMe oxTie(1
❑ Yes ❑ No
It owned wiN sameo� othar ihan spouse. iMicata w%h whom
Is Ne propeny in puestion: Mnualty Asessed
❑ Real Pmperty ❑ ArmuaOy A�esSed
_,_,,-�. ao��. ..
} .. . .
WhalTaringDisl �.'� \0••••
� p, ���� � S
y. ��...�����
AUOROR C;�1 � �O' •• , ci�
1, ,a, U"
� � \ � `-' � l�'
— I ni— �" �
Counry
Date (rtaNh. tlaY. Y��)
I I We certify under Ne penalry of perjury ihat ihe above and toregoing infamation is W e and mrtect and that the applirant is a resident of Indiana aM
owner I mntract buyer of the aforementioneE property on dace appiicaaon is filed.
�namre (uwne{s ru�me) , . A oate (rmmn. ear. re�
�
by IC 61.142�J
person (number mM sneet �iry. stafi.