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'�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS u T p ear
__ _ FOR DEDUCTION FROM ASSESSED VALUATION
Sfate Fwm 43709 (R71 / 6-09)
� PresaiGed by DepartrneM af Lo�l GwemmeM Fuiarrs
�" MARF��
wsrnucnoNS:
Fwm f�ed wRh:
b be filed in person or by mail witA the CountyAWitor or Counry Recorder o/ the county whele the propeRy is located. ,_ ��/��
Fiing Dates: 1) Real Pmperty Must file dumig Ne year fw which Na deduction is soughL 6� F�wtt"'v q�d��
2) Mo6de / ManufaUured Flomes not asseued as Real Propefly: Must file dunng the M1veHe (72) monfhs -[�j v- � ° er
befora March 31 o/each year the deduction is saght GIBSO COUNT�°�
See 2verse side /or additional instiucUons aiM qualifications.
��
T' '� Key ruanbe+/ legal desaiption Record rwmber Page numbrl
O - o- �►s_ o�. S�8- o a7 0� 403/
rdue d rral prope.rty as of Mortpag e/ Cantrati inde6tetlness unpaiC as W Mortgage / Contrari inEehtedness unpaM az o( b Ne app�imnt the sde
MerN 7. nrmnc Year Mart�h 1, artent_ yeer ��" te of a7Plifation � a M�ntable owneY?
�-��-�-�+-��i i�EJ �Q��� ❑ Yes ❑ No
tt ro, what tr h'a / Mr eYaf1 share ot interest? If ovmed with sdneo� oCwl than spousa. IM�icete with whan
tl nama on 2md'a 6Re2nt Wn Wt d apP�t InOVate bebw: b Ihe VoD�Y in Curstion: Mnuelty AaesseE
I Reel ProPertY ❑ ��Y �
Name af mortgagea or mnaaU se4er
mormauex or mnaaa
owner
�Y.
sneeG �Y. sleh. antl ZIP cotle)
o� ap��,c �, v�a�m � aM w,�,
oouHY m UW�e�u? ❑ ves
DeCudion appmvetl in Cre a
20 _
Sg�nne d �Coun^ty Au�d"rtor
_�
/ Y✓�
I I We certify uMer thi
owr�er I contracl buyei
20 _
�,�.�����
COUI
20 20
y of perjury that the
atorementioned Droi
d appfieant (numDer an0 sbee4 �: �ta.
a�o �v /�r�'N c �e �{
awY e.eaaea rower anm„�y «eY �c f
o( autlioraed persan (num0era�b snee; dry, sfate. anC
— �
Dra"�er to....
�Q02,.... _
4Vhat 78vm ry
���-�.o.....40.� ........ Na
�— � p-
Date (rrniW. daY. Y'��)
20
nd toregoing intortnation is true and correa aM that Ne applirant is a resident of IrMiare aM
date aPGliqlion is filed.
Date (rtmM. daY• Yaa�)
70