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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE o ip vear
__ ; FOR DEDUCTION FROM ASSESSED VALUATION
State Fartn 43709 (R71 / 609) � �
� Presaibed by Departmeril of Loml Govemment Fnance
File Mark
iNSrRUCnoNS: UEC 1 F�,A�,�m
To 6e ned in person or by mail with the CountyAudifor or Counry Recorder o/ the counry where the pmperty is located.
Fiing Dates: 7) Real Property: Mus! fife during the yrear /or which the deduclion is sought. � Counry Aud"rtor
2) Ab6de /Manufactured Homes not assessed as Real Propery Must file dunrig fhe fweHe (72) m�is�,,, �
6etore Marcfr 37 07 eaM year the deduction is soughG � '/�1 Ca+nty Recorder
See reve� siCe /or additional instruUibns and qual��ations.
GIBSON COUN � ..
'.M wnerorcwrt+aCbuyer-seamsMCaonsai2 sida)
�C.r:�IGiT^RS*
If ro, what is ha / hu ezaG sha�e of inleresK
-- � 03_00�. ,�-o�� _ao s�3
brtgage / Contraa Intlebte0rress unpai0 as of Mortgage I Con7aa indebtedrress unpaid as of Is Ne eppGmnt ihe sok
la� 1, airtent date of appBCat»n legal p epuita6le wmM
D D ❑ Yes ❑ No
If awnetl wiN someo� other W n spouse. iMkate weh wlbm
tt fwrie m remtl e Ctlfrlmt Nan ihat W aDV��1, ma�tc hehw.
rtMxtg3gee m m�trxt seDer , w �` ��)
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� i
of nvlgagce w mntraU se0er (numbe and snee4 uN. s+a[e. eM LP code)
Name of assignee w oihe� ovmer w hdder ot rtnrtgage
AdErea oi assg�Qwmber and sneeS �Y. stafi, aM
Daes epplipM am property in any oNer
muMy in IMana? � _ _
ar
zo 1 zo
I 1 We cert'rfy urWu the penal
owner I mntrad buyer of the
COUNTYAUDROR
20 20 .
� Caunry
thal Ne a and toregoing infortnalion is true ai
�ned p on dete appiicalion is filed.
�e property in Quesfion: MnuaDy Assessed
Real P.oaenr ❑ /'��M �
�ueim Eers reQuesteA m prapnity
� ❑ ves ❑
t� o� ��-( fC K�
q�0/0 ��3�
F�ID resident ad@es of appGOnl (num�4� antl sfreet aN, s+af61 � LP ootle)
I�I N�1 � sy- Pai,v��e�J �f7� 70
Pelson auNOrizeE Ey duty esecuted Power ol ARaney or by IC 61.1-12-0.7
Pddress of autho�d puson (numberaM stree( dty, stafe, an0 Z!P code) .
� Date �a...... --...
Date (monlh. d�y Y��