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^�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS C e Township Year
_, : FOR DEDUCTION FROM ASSESSED VALUATION
. . ' � State Farm 43709 (R71 / 6-09)
S d p��bed by DeP�eM af Local Governmerd Firwrs
"" JU File Mark
INSTRUCT10N5: A.
To be filed in person or by mail with the County Auditor or Counry Reoorder of ihe counry where the pioperty is located.
Filing Dates: 1 J Real PmpeRy: Must file during the year (or which the tleducfion is soughf. C��� unry Aud'rtor
2) Mob�le /Manufactured Nomes rrot assessed as Real Property Must file dunng the fweNe (12) months
6efore March 31 of each year the deduction is saght. nty Recorder
GIBSON C
See �eve side for additional insfructions and qualfications.
Aoofuan ( arcontrarl byre/-see psf.q'Uions m reverse siCe)
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f vahie dreal popgtY as d
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Key rnmber / legal desaiP� Rem(d numher Page numbel
a�-�9-i9 - io3-oo� � 9 s�-o i z��-
Mor�qa9e / ContraG "v�dmted�ress uMad as W Mortgage / ConVarl udehttdness �sPaid as o( Is ihe �G�t Ne sde
Marti� 1, airtent yrar date of aPP��b^ �7 legal a eWitade ovmM
I D6 �C7L7 ❑Yes ❑No
11 ro. Wh3t 6 h61 h¢! CT9C1:hdf0 Of VIIPfP3l�7
If'ame m�emrd is EiRe2n� Nan that ot appficari
Name W rtrort�a9ee « contract se4er C
J
nAAmc of mortvaorP w contrsd sWer (numbei�
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' e of as4gnee or a�hn+ wmer ar holdu of mort9age
MCress of assignee ( mbe� end srtee4 dl: �te, and ZIP �J
/
Dces appli�nt wm yoperty in any oN Ii yes. whe
munrymindana? n Yes ❑ No
IF awned wrth mmeone
TariM
IS th¢ V�PQrtY Ifl QII¢SLOn: MN12M ASSCSSCd
�Rea� Ropertv ❑ M^ualN Pssessed
Modle Home fIC 61.
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