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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDN� Coun Townsl
, FOR DEDUCTION FROM ASSESSED VALUATION
s�e F«m aa�ae (Rn r sos> v
�' ,,,, � Presmbed �y Departrnerd of mme�rt Fu�arc< �
. �
INSTRUCTIONS: (�(�'j (� � m� �:
To be filed in person or 6y mail wiN the CountyAuditor or Counry Retorder of i em _wh� pe71}�is'lor�te� 2 � �
Fii"ag Dates: 7J Real Property: Must file durng Ne yaar lor which the deductio i�iyht. � Counry Auditnr
2) Mo6de / Manufactuied Homes not assessed es Real Property Must file during Ne twe1x�1�J monMs
before March 37 oleach year the Ceduclion a mqht. 0�(6� ,Q� ❑ Counry Remrdu
See reverse s�� R^• -ad»'^^-� %nsLUCtbns and qualficatans. � GIBSON CO 1
�M �b��- ^ ���) . F' : 7� TY hb6 . /l �
T� / •W,� I �Y
As�sed vaq�e oF � VoP�Y as d
Atarrh 1, a+m¢ yea
If ro, vAat h his I lcer erxY share of intse
nafne
Nartre of rtart9a9�
dRFerent Nan Nat of appOCani, uWira� Eebrc
Mdress d rtiorqagee or contrau
wmer w nmer m mvtgage
antl saee; rdy, slate, antl ZIP cotle)
Does e�i�nt ovm propeM1y in any oNer
counry m Intlana? � . .
Y��
a
tlace
/ [.x.CLV7l� /V �
Rxortl numEer Page number J
'�� �
�ct cWebtetlness unOaM as d
H ovme0 witl� sortw�ne other 4�an spouse.
R�e
Yes
prm� m Vu�tim: MwaOy Assessed
PnPeKY ❑ Mnuai�YA�s�
Nas Miv deduction Oaen requesteE m prope+ty
tar curtent yeaYl r-i ., r-i
No
No
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