HomeMy WebLinkAboutMortgage_Keene_^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coum
FOR DEDUCTION FROM ASSESSED VALUATION
• State Fortn 43709 (R71 ! 6-09)
S ! Presaibetl M �eP�nt o1 Local GwemmeM Firence
�1STRUCTIONS
To 6e filed in person w by mail with the CountyAuditor or Counry Remrder o/ the wunty where the property is located.
Fil"mg Dates: 7) Real Pmperty: Must file dunng Me year for which the deduclion is sought.
2J MobBe / Manufactured Homes rrot assessed as Real Property: Must file dunng the twelve (12) months
befae Marth 37 of each year the deducfion is sought.
See reverse side (or addilional insfrucUons arM qualfiwtions.
an t(e normntrarlbuw�-see m2versesidel
A�ssed vWue d r� AW�Y as d
Ma�U 7. arrrlrt Year
tt ro, what a his I her e�mG share of interest?
If iwrie m iewtd
r I iegal tlnsaiplbn
�O� 3 3 - �a o - do /.
AbRgage / Contra�'uWrbtedness unpaid as of
Martl� 1, wrten[ year
a cantract se0er (nuMerand sneel
w other ownet w hdder at mntgage
P4dress of assicyiee (numGar aM street rny, state,
�
!za
artnunf ot
�I1T�'Al
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20 � 20 _ � 20 _ � 20
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n
�^I R �ount��}�imr
�Caun Remder
J.
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v
GIBSON COUNTY AUDITOR
RecoN brs P numbu
D� 3 S
unpaid as of Is Ihe eppOmnt Me mle
� legal n equitable ame(�
❑ Yes ❑ No
�1-5-�fe P�PertY in Que5lion: Mnua�y A55e55ed
�''tealFmPeKY ❑Mnual�YPssesud
�� � N� ��
��� s3s
��
I/ We certify urder the penalry of perjury Ihat ihe above and (oregoing information is true and wrtecl aM fhat the applinnt is a resident of I'Wiana arW
owner / conVact buyer of th�aforementioned pmperty on date appiicalion is filed.
u�aO�eY I Date lrtnrun. daY. l�ean
s of apprirant (num6er antl shee4 �3; s+are,
f^ t�K/�� D�✓�.
Gy duty executetl Power of Auvney rn by IC i
permn (number aM street, dry, sfate, antl ZIP oode)
Date (monN, daY. Y��
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