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"� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS C own ip ar
_ FOR DEDUCTION FROM ASSESSED VALUATION
Stata Farm 43709 (R70 /71-08)
� � Resaibed bY �PaMient d Loral Gwernmerd icmnw
INS7RUCTIONS: File
To 6e filed in person w by mad with the CountyAWitar d tfie county wlreie the propeAy is Mceted.
Filing Dates: iJ Real Propelty: Must file Cunng fhe year /or which fhe deducb"on is sovght. ¢�.,
2) Mobile / Man�lacfwetl Homes not assessed as Real PropeAy: Must fde durng the fweNe (12J montlu 6e are M�h��NCh year
thedeCuc6onissalght GIBSON COUNTY AUDITOR
See rever�de (or atldNOnal insWCFions end qualficefims
n mNiaci Mmr- see resbiCions m iow,as sidel (_ i
Assessea ralua m �ea� propery as a
A1amI� 1. airtertl yex
tl ro, wha� is his / �er e�mtl sha�e of iIk
u imme m recad is a�erem uw, ual a
Narne d mo�igagee a conbacl se0er
AEdrass d morlpapee a mrtad setler
Name d assignee or aNer owner ar hoF
mmber / lepal d
�/o.O�f' ot 5 - 03 - �
MM age / Con�rad'mdeMednass tuqvid as d
��,.��Y�i�n D l���o
df}: slafe, ar�d LP cado)
Does a�pl'rant own pmperty in arry dher I If yes. whal cwM'T
counry m IMare1
n Yes ❑ No
d'an appmved "m Ne amaunt ot
20 �9 20 20
/�g_v �v
az
r equipbla ow`reR
❑ Yes ❑ No
SMIB0f1B WIBf �IWI SP��. OWCdIB WIUI WIIMfI
k Ne v�OeM � auestmn: anm�aM nssesme
�RealPropeAy QArinualyASSessed
i�o3�-t �
��� � �
v�aeM
❑ NO
� �
�
20 _ /�,' /�1
� v ^ � � I Data
I/ We certify�el the penally of per�jiry that the abave aM foregcting uifartnatim is true and cwred arM that Ihe appG�ant is a msdent of Indaria and
awner I mn d buyer of ttie aforem��ntiwied property on tlate appfication is filed.
SignaWra (�d- / —'�'7� Date (monN. daY Y�
/
Full resident add s d eppfiran� ( ermd dty, sta�. andZlPmOO)
lj �i •¢ /(/�f%���
Parson a Ww�¢ed M W execvted Power tlA2tomeY a by IC 57.1-12-0.] oaie (mo�rn. ear• r�
Atldress d autMr¢ed 7arsan (number and s�cel dQ'. sbte. and LP rodo)