Mortgage_Umpleby^'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS vear
• FOR DEDUCTION FROM ASSESSED VALUATION �
• �T � � Stata Fwm 43709 (R71 / 6-09)
�' ,.» � Preurbed M DePartmeM of Local GovemrtreN Fiiarxe
wsrRUCnoNS: APR 1 �����`
To be filed in person a by mail wifh the CountyAWitor or Counry Recorder o/ the counry where the properfy is located F� �� ��
Filing Dates: 1) Real Property: Must file dunrg the year for which the deductiwr is sought ���' un Auditnr
2J Mobde / Manu(aCured Homes not assessed as Real Property Musf hle during Me hveNe (12J months ry
6efae Maich 37 0/ eacA year the Ceduction is saqht. �e�
GIBSON C UN A F�
See 2verse side 7or addilional ins6uctbns end qualifications.
ADc�, (owrrerorconfrdC6uyer-see mre�vsesiie)� �l
d(/n .., ; . p � - //.►.,� /�ci�1i-+2
',fs, `�Lt�/�� I o?
��«����
i 7, armnt yrar
what fs ha / her exact share o( interesi?
-o�t-Ly-
Mor(page / Conbaa inde6te
Marr3� 1. arrent year
If name on �eCqtl a 6Reran than tltat ol a0p�pn�, cMitltB below.
Name otmM9a9ce «mntract
nnrtgagee @ wntrad seoer (^�mn r entl� sbeeL raY• smfi.
C A�. i
lil�i/"D�O�i �
si�ee w other wmer or halda ol mortgage
assi�ee (number eld sbee4 M: sm+e. entl Z/P code)
Ooes applimnt axn MoDenY in any dher
counry in IMana? � � Yes
Deduction appfoved in fhe amoum ot
za zo _
SigrenuedCamryn�waar `
If yes, what munry/1
zo I zo
�o_oc .s87.o,8 -aoo �__03
id as M Mongage I ContrarY uWebtedn�s unpaid as of U Ne appluant the sole
DDO tlata of eppOCation kgal w aquttade ame(1
❑ Yes ❑ No
M owned with someorre othar than spouse, ind'�te with whom
is ihe p�operry in 7unsbon: MnuaDy AtsesseE
� Real PfoPeRY � ���a�'1 �
Whal Tadtg Di
Dra�ver NO....:a�9......
worcoa 3� b3
Card I\'O . .....................
� S � p�0 , 6L�
camy � oa� (�rn. aar, r�n
I I We certiry uMer the penatty of pe�ury �the above a,�egoing infamation is We and corteG and that the
owner I mntraa buyer ot ihe aforemention property an �4jE applkation is filed.
^J
ny ic
person (number aM sLea4 �y. sYdro, an0 ZIP mtle)
. ����y
resident of IMiana aM
oa� pr�m. d�: r�e�