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"�n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship vear
,_ • FOR DEDUCTION FROM ASSESSED VALUATION
�• State Form 0.3709 (R71 / 6-09)
S,�,� 1 Presaibed by DeD��rR ot Loml Govemmenl Frence
ie
INSTRUCTIONS: Wmy
To be (led in per5on a by mail with the Counry Auditor or Counry Recorder ollhe couniy where the pioperty is Iocated. �� c�1 I Z
Fi7iny Dates: 7) Real Property: Must file during the year for which the deduction is sought. County Auditor
2) Mo6de / ManufacNred Homes no1 assessed as Real Property: Must file dunng tAe hvelve (tt) months C�J.Ir
6efora March 31 0/ each year the deduction is sayht. u ty Recorder
See reverse side lor addiliona/ instructions and qualifications. G I B SON COU
MP� (ownerorcontraC6N'�/'see ' 2verseside) /C�a�-C.f���.2�
L7
T'ng District _ Key number / legal desai Remrtl number Page numbu
M3rch 1, aamn[ yPar
tt no. what is 1� I trer eraa
If name on recud is drtFera
- _/Do,DO . Gd'6 -b
MoRg�ge / Contraa vde6tetlness unpaid as o( Mortgage / ConV
Mar� t. wrtenlYrar Eate of aPP��b
�
tt oaned vriM mmeorre ott
Nat of aPP�aN. udimte Ge�o'�':
mwtgagea or oontrad seller
of mon9agce a canhact seA
asv�nee w oNer a�mer or Y
ci(y, sfete. aM ZIP code)
riry, state, and ZIP oode)
pm pmperty in any oNer If yes, what
�� ❑ Yes ❑
duction app�oved rt� ihe amwnt of.
2a_ p �—
�riature ol Co�mry AuGimr
� :T Yh-���,.e
I I We certify under Ne penalry of perjury t the above
owner I cantract buyer oi ihe aforementioned property o
33i�
unpa' as M 4s the applKant Ne sde
legal of eGN�ae oxme!?
) n ❑ Yes ❑ No
h tl�e P�Den1' in QuesSOn: MnueAy 0.ssesse0
❑ Rea� Roaertv ❑ armua�y Assessed
°�•O�- -
4N�a1 Taring Dis�ricl7 - •-^ �his dCdueiion Eeen �eQiRSted at p�opelty
~ - �r1_ves ❑ No
COUNTVAUDfTOR ����� "_" `U�-C `/---
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Counry
���o, ��, �
oing infortnation is We and mrtec[ a�N .._
rication is filed.
Date (,mrCh �eY.Yee�l .
F�ID �deni aCtlrev^�eL�pp(�n� (num0arand sLeet dry, stare, aM LP code)
�3a3 �� Ip�o S• , Owru.�svc���
Puson aut7qraed Cy auh/ ezecuted Porer of or by IC G7.t-72�.7
Pdtlress oi aulhw'¢EO G�^ (numbe! arM 5Lee4 dry. sfate. aM ZIP mtic)
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