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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Townshi Year
__ � FOR DEDUCTION FROM ASSESSED VALUATION
• State Fwm G3709 (R71 / 6-W)
� 1 PreuribeC by �epaRmenl 01 Loral GwemmerG Frwice
�� File Mark
wsrRUCnoNS: JAN F
To be filed in person or by mail wifh the CountyAuditor orCounry Recorde� o/ Ne county where the pmperry is located. '
Fi/irg Dates: 7J Real Pmperry: Must file dumg fhe year /or which the deductan is soughG ('� � Counry Autlitor
2) Mobde / Manufectured Homes rrot assessed as Real Property: Muct file dunng the twelve (72) months '
before Maich 37 0/ each year the deduction is saqht. unty Recader
See reverse side (a addRtional instructbns and qual'dications. GIBSON CO
Apw� t(owner ar C buyer- see 25MCLins on rew side) �( 7
•-f�.�-�r `��i /'%1a.u1�.� Gi'�Z-Gee�a�/
aUi 1. avmlrt yr.dr
110. Wh816 h15 / h¢! 8I2G Sh218 0( 4
�wre m �ecold is NtfuPnt Nan Ihai
ame ot rtnrtaaaee ar mntrarl uYa
rcey �mn� �i ae:a;oro� O • �,�m
�o - �a-o? -/o!_ o v. 863-oa-8 �0
M�a1 Qairterrt �IMrbtedn�s unPaid as af Mortg� �P�� udehtNnesv un7� as d
Mtlress oi mortgagee or contract seAer (ni
Nym¢ uf assignee w ottml owner w haider
Mdrey of assiy�ee (numOeraM strqCA d
' 1 .r( 1 ��/
AC u I�C.CYI� 7 0'
D�oes aPquant o+m pfoperty in any oNer
counrymintlana? ❑ Yes �
DeduGion approved In tlre amount of:
20 _ 20
Sigrenae d Cau�ry nua�
r'.T. �
I/ We cerUfy undu the penalry of
awner I contraG 6uver of Ne ator
�� � w .
Pe�son authofrzetl by Auly ezecuted I
re( aM s3eeG �Y
mortgage
srefe LPCo
It yes,
No
�
ry that Ne above f
ntioned property aL
�
7 stree; rlty, state. antl LP
✓A�.� u'� �
AttorneY � M IC G7.1-12-
someo�re otlier C�an spouse,
RoPeKY ❑
Dra���er NO...c���1..........
madeo�neR
Yes ❑ No
M�IIBIh/A55e55e0
tleEU�Lm Eeen re9uested m prapefty
Cal'C� �i�. .... �� ............. ..iyean � ves ❑ No
person (numDeraM SbBel �: sbte. an0 LPGOtle)
C.��/IV 1 i NU V� � v�.
20 _ 20
��b
Pi�7
Date (mwvn.
PZ�,
intortnation is We and correU arM that Ne applicant is a resident of IrWiana arM
ion is filed.
Date (monfh. daY. Ysa�
�`.v 5�7 ��7 �
oace c�, aar. ree�)