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ry� STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
., __ _� FOR DEDUCTION FROM ASSESSED VALUATION
• Slate Form 43709 (R71/6-09)
, 1 Presaibetl by Departrtrent of Locai Govemment Frence
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INSTRUCTIONS:
To 6e fiied in person w by mail with the Co�ntyAUditof or Counry Recorder o/ Ne counry where the piope
FiNrg Dates: 1) Real Prope/ly: Mus[ file dunng the year for which Ne deducLOn is wughf.
2J Mo6i7e / Manufeclumd Homes not assessed as Real Property: Musf fife dunng the fwelve
befo�e Ma�ch 37 of each year the deducfion is sought.
See reverse side for additional instructions and qualilrcations.
�n' (oi�-'m/�il / �7f � D( /Y}A�� / / e) L JL�.M�
Coun Township Year
��
File Mark
rtyis t
F��io y Auditor
(1 monf s
❑ Counry Recarder
��T 1
C
Oistria Key fuunCer / legal desaiption RecoN number v Page numbrl
'��- (o - DO -�O/, �j3 _OZ � GIBSO COUNqY�UDI OR � �1
rd vapie U 2al 7oP�Y as of Mortpag e/ Contract indehtedr�s unpaid as af Mortgage / ConVarl mEehtedness unC� as d Is Ihe sCP�t tlfe sde
t. nrre�rt year Ma� t, artent year tlate of apP�� legal w epuitahle wmeP
I DD D�O ❑Yes ❑ No
tt ro, what is his ! her esact share of intrlest?
If name m �ecord o Eillerent Nan
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Pddrea of nnr4�agce or cantraU se0er (nurtibu end sveaf, �y. sb�. ard ZIP code)
w Wher ovmer or hdder of rtqRgage
Atltl ot =eei�nce (num6er aM stree4 �aY, slate, 1
�� �v � 3�- 3-
Ooes applifant ovm pmperty in any olher
If wmed wiN
coae) / `� ? � �
D'a
spouse. I�kate Kitl� �Niom
Is Me m Questian: Mnuallyl�ssesseC
eal F.overtr ❑ MnuaM Assessed
MobOe Fiort�e QC 6-1.1
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