HomeMy WebLinkAboutMortgage_Cox^�� STATEMENT OF MORTGAGE OR
_ : FOR DEDUCTION FROM ASSESE
� � . :• S�ate Form 43709 (R71 / 6-09)
S, � Presaibed by Department o( Laal Govemrtrent Fnana
!�NSrRUCnoNS: NOV J 2011
To be filed in person w by mati wifA the CounryAud'nor or Counry RecoNer of the counfy rope rty is located.
Fi("ug Dates: 1 J Real Property Must !le durirg the year for which Ihe deduction is soug��'�^�����""�"J
2) Mo6de /Manulactured Homes not assessed as Real Pioperty Must file dunng [he 2) monMs
6efo�e Maich 37 o/each yearfhe deduction is sought. GIBSON COUNTY AUDITOR
See reverse side for a,d�fronal instrucfions arM qualifications.
Key rwmf[e{ / kgal desrnption
a
H ro, what s his / her eraa share of intrlest?
If name on remrd ¢ QAterent lhan Ihat
�9a9e �
M2lC)1 i.P
File Mark
F«m �aea wm:
� CountyAUditnr
❑ County Remrder
-t/`c�. ���� / RemN rwmbp�� Pa9e m�m0er
� 50 '
mss unpaiE as of Mwtgage I Contrad'vdebtedness unpai0 as d Is Me eppfiont tlu sde
I�/y�� date o( aOP�� �al «eWitade owre(�
J( ,� ) ❑ Yes ❑ No
w contracf se�a (nurtNererd stree4 �Y. �. aM LP oode)
w otha ovmer u holda ot mortga9e __
/waress ot ass
- a,o��.......
Dces appli�ant � .
�������: Dra�ver N .
Card NO. .....r.�. ���....
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�— , �_ I 20_ Zo_
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I/ We certity urWer the penalry of perjury th�t the above :
owner I contract buYer of the afwementionld pmperty on
antl sLeef. dry, state, and ZIP mtle)
Dy OWy exeated
person (numberaM sbeet ciry. slafe, and ZIP ootle)
What Ta�arg DaVicl7
zo
spo�se, iMicate with H1iom
Is tM piopeny in quesGOn: MnuaDy Assessed
❑ Rea� Provertv ❑ tvnwaly Assessed
Has this tletlutlion Ot
�w���
�
stea on pmpeJty
Yes ❑ No
� ��. �Y ,��
zo
infortnation is We and cortect and Nat the applicant is a resident of Indiare aM
ion is filed.
Da[e (nmN. daY. Y�h
Date