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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ovmship vear
_ ; FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R7116-W)
�' ` Presaibed q Oepartment of Loml Govemment Finance
il Ma
wsrRUCnoNS:
Fwm tde0 with:
To be filed in person or by mail vnth the CountyAuditor or Counry Recolder o( the county where fhe property is located. U E � c� �n n p ty
Filing Dafes: 1) Real Pmperty: Must !le dunng the year (or whicA fha deduction is soughG �� �Ln Auditor
2) Mo6ile / ManuFactured Homes not assessed as Real Pioperty Must file dunng tAe 1weNe (12J months
6efore March 37 0/ each year the deductnon is sought. ❑ Counry Remrder
See reverse side (or additional inst ctbns end quali�cafions. �
np� t(o»nerorconvaebuyer- onreversevee) GIBSON COUNTY AUDITOR
Distriti Key numE¢r / kgal tlesaiP�+ � O�. � 7 C— O � Record numEer Page numDer
� a�-�2,-0?-�03- � 2? a-oo9 �87
eE raNe of real property az d Mortpage / Contraa irde6tedn�x unpaid as of Mortgage / Convart indebteArress unpaid as ol Is Ne epp�nl Ne sole
1. amnt yrar Mamh 1/. a�irtent yenr /� dare of aPP�� kgal or epultable amel.+
(o D C�G��000 ❑Yes ❑NO
fiaf's his / lret eraC shara of intemst? tl ovmed wkh someorre ofher than spouse, itWi'ste with whom
m
Name of rrortga9ee m m�t2p u9er
Address d mMgagee or mntraG se0er (number end w§§[ cGy, sb�, ard LP cade)
assi�ee a other ovmer or hdder of mortgage
strce4 �: s+ete,
any
munry in IMena?
Deduction approved In the amount of.
zo _ zo _
Sigrunrte of CounryAUditor `j
/�
1 I We certify under th penalry of perjury
owner I contract buyer of the aforementio
COUNTVAUDROF
20 _ 20
Counry
Is a,e a�vem �� a�rion: a,m,aM Asussee
❑ Real ProPenY ❑ A^^�Y �
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D�•a���er �p..........
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Card ��• ..........
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_ i 20 �
Date (month. day.Yea�
�
20 _
above and foregoing infortnalion is We and cortect arW Nat Ne applit�nt is a resident of Indiana antl
)erty on date aDP��Cation is filed.
6+lfl resident aGtlr�s of appGrant (number entl street, dty, sfate, ard ZIP code)
y t � ,�3Rown /ee ,4vtNV�
Person auttromed Ey duly exewted POwer of AttOrney or Oy IC 67.7-12-0.7
person (number arN sbee( crty, state, an0 LP mde)
% 0/li T_i1 / �/ 7 6'70
Date (montn, tlay,
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