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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun hip Year
• FOR DEDUCTION FROM ASSESSED VALUATION
;, -- - .
State Fortn 43709 (R17 ! 6-09) _
' Prrsoibed by Departme�ri of Loral GovemrtreM Fuiance
�STRUCTIONS: .1 L 2 �����
To 6e filed in person w by mail with fhe CountyAUditor or Couny Recorder of fhe county where the pmperty is loc�t�. F� ���
Filing Dates: i) Real Property: Must file dunng the year Por whicb fhe deduction is soughL �. �, County Audiror
2) Mobde / Manufactumd Homes lrot assessed as Real Property: Must file dunng the hvelve (72) montlis
befae MarrAr 31 07 each year the deductiun is sought p�[t061y Recorder
See reverse side loradditional instrtictions arM qualifications. G�gSON COU T�
,��„^� Q�� b�- s� ,� �� �'0 �iYl�7�
�J l2r.� � n ni.
Asesud �/Aue d 2al p�opertY as
A/a�U 1. aneitl year
I( rw. what
�idress o1 rtartgagce or mntrad se
Name oi assignee or oihu owner w
Aearess of assignee (number eM s
oi app6�an4 6Wicate bebvr.
c�ra
cdy, sfafe. eM ZIP cotle)
property in any oNer I I( yes. what muntY?
❑ Yes ❑ No
itre
20 � 20 _ � 20
Eate of appGfation
I num"hei Page wm0u
� a a$5�
as of Is the eGP��^t tlx sole
legal w equita6ie ownM
� Yes ❑ No
If owned wiN mmeor�e aher Ihan spouse, indrcate wltli wtwm
Is fie proprlty m C� MnuaOy Assessed
❑ReaIROPMY ❑!0!muallyASSesud
llrawer NO....�.�.Ql.�......
Carcl NO. ...a� Jc�o........ —
VJhatTa ���w.� " ""_" ' . �'pettY
- ' I fw artent yeaR ❑ Yes ❑ No
AUDROR
20 _ � 20 � 20 _ � 20
oate (rtbnfh. day,
1 I We certry under ihe penalry oi perjury Nat Ne ahove and foregoing infortnalion is true and correct and Nat the applinnt is a resident of I'Miana aM
owner I conVad buyer of ihe aforementioned pro0erty on date applicalion is filed.
inature (ormers hA rumel . Date (monN. daY• 3'aa�
i /fS' S �'a,
autho�@ed by dWy executetl
slate,
IC 61.
PddressofaWwr'¢e�persa� (num6era�ASneet,dy.state,andLPCOtle)
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