HomeMy WebLinkAboutMortgage_Smith (17)^�� STATEMENT OF MORTGAGE OR
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� FOR DEDUCTION FROM ASSES:
� y Stata Fotm 43709 (R71 f 609)
S 1 P�esaiy�y py py�yrtmenl ol Loral GovemmeM Frarc�
��rnucnoNS: MAY 1 2012
To be filed in person w by mai/ with the CountyAUditor o� Counry Recorder o/ the cnunry\�}e ro rty is located.
Fifig Dates: 1) Real Property: Must file dunng the year for which the deduction is s^eugM'.
2) Mo6de / Manufactured Homes rat assessed as Real Properfy: Must file dunng t (12) months
6etoreMa/ch37ofeachyearNedeductionissaght. GIBSONCOUNTYAUDITOR
See mverse side lor addi " nel instructions and qual�cations.
AppGCant(ownerm b rc +se " )
p�Ae rdue d re� propeny at o(
Marrh 1. ameN yer�
tt no. what is ha ! trer esxt share of u
It nd1112 m RMItl 6 NRPlW Itidfl Na'
Name of rtanpapee m mntract se0er
AAdress of rtm`baar� M �'+�+'" °m
File Mark
Form t�eO wiih:
County Auditor
County Remrder
ga des O — I��� .., ^�., /Yl L` ��/7� Remrd nu O/ P�e ��0�a
I ��� 'u� �• 7
1or��age / Contract intlebtedness unpaid az of Mortgaga I Con� 4We6tedness unpaitl as d LS ihe eppfmant the sole
7amh 7, artent year � date o( applintion legal or equitade awneN
❑ Yes ❑ No
If avmed wiN wmeone othr! ttun spousa. iM'xate wiC� wlrorn
uq'xate 6Elow: Is Me P�PertY in VuesOm: Mnua�Y A55essed
❑ Real ProPeRY Q %��Y �
,. „ ,.. _ . _ MoW'le Hortie tlC 61.1-7
Drawer \`O. �I•a •••,
' Card NO. �1�........
I �g�,���� �
20 _
Sg�awre ot N d
I I We certify unc
ownerlconVad
20 — � 20
;natty o1 perjury that e above and
the aforementioned perty on da
- o
ezecutCC
P4dress of aWror¢Ed person
'cada)
VJhat Tavng Disiricl7 Has N's
— far arre
GOUNTYAUDROR
ej a�nA SLeet. te, and LP cotle)
7`���uPNG' Li
iuer NAnomev or Cy Ic 61.7-7 z-0.7
arM sLect, ri(y, stlte, anE ZIP ootle)
20
Caunry
20
2Q
Detc (rtmN, day,
sfetl m D�Y
y�5 ❑ I
20
intormation is we and correct arid thal the applinnt is a resident of I�iana aM
ion is filed.
Date (month, day, yea�
�S
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