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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS C ,TOVtnship Year
FOR DEDUCTION FROM ASSESSED VALUATION ���
:• Sfata Fortn 43709 (R71 / 609)
�` � pr¢soibeA by DepartmeM af Lxal C»vemment Fnance
File Mark
�S7RUCTIONS: Q �
� .
To be filed in person or by mail with the CountyAuditor or County RecoNer o/ the county where fhe property is bcated.
Filirg Dates: 7J Real Pmperty Must file duririg the year fiu which tha deduclion is soughL C'�. �' �°"' ry Auditw
2) Mobde / Manufactured Homes rrot assessed as Real Property: Must file dunng the M1veAre (72J rtronths � �
betore March 31 of each year the deductlon is sought. ❑`C� Recorder
GIBSON (' ' "'T � nir o
See rever�e side for addiGOnal instructrons arM qualifications.
Aoo5n owne� or wntrart bwer: se7r�sfrir�uns wr iavarse sif11 _ / �. . I
.,,� �.-
ea radre d mal poperty as ot Abr�qage / Contraa tr
7. amN 1� Marrh 1. airtenl yrsr
Ii rq, whal's h's / Inl e� 5hale O( interesi?
If narne on RCMd's 611urnt Nan that ot aPpGpnt, mGiCate Eebw
Name of nrortgagee a cantract sHler
Address of mortga9ce w cantracl sWer (num6ri and stree; cdy. sfete.
Name af assignee w atlml awner or twWer ot rtqrtgage
ACtlress ot atisiqnee (nurtrber erd s0ee4 M: sfafi, and ZIP co0e)
Dces appl�nt ovm pmperty in any oNer If yes, what mun�/1
couniy in IMiara?
❑ Yes ❑ Na
unpaitl as of
�i
mmeona
WhatTad� DistriCT
�Remrtl number Page num0er
o �a �" �
b�,���,�b�� ��e��,��
kgal w equitade amen
❑ Yes ❑ No
sP��. rtdkate wiM xlmn
is IM P�7ertY in VuesUan: Mnuelly Assessetl
�Real HvPerty ❑ %vmually Assessed . . .
m property
......... . ............
DeducGOn appmved 4i tl�e amoum of: I �..
Dra�ver NO.:....... .......
zo � zo_ 20� zo_ �-15� 5
I c���� �o : ....:................
�����ry�;� I �� �-R��P �a3�5�a.°°
—
I/ We certity uMer ihe penatty of perjury that ihe above and foregoing infortnation is we and oorre F�, _
owner I mntraa buyer of the aforementioned property on date appliratian is filed.
SimaSUe (owne/s NV rtamel ._O � Date (nnirth. daY. Y��
��
(number anO sbeet,
a�,�, o� � �� � ,.,-, z-0.�
of autha'¢ed person (numberarM sbeet, dry, sYdte, eM
y
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