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^`� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
__ • FOR DEDUCTION FROM ASSESSED VA�T�- ��
� State Form 43709 (R71 / 6-W ) pB
•�' , Presmbetl by Department o1 Laal Govemmenl Fl�nce � Y-.J
�JSTRUCTIONS: (� (`� ] (j',
To 6e hied in person w by mail with Me CountyAuditor or Counry Recorder ol thA'c47Jntywhe�`M�property is located.
FrNrg Dates: 1) Real Property: M�st file dunrn� the yrear /or which fhe deduction is 5ought.
2) Mo6ile / Manufactured Homes not assessed es Real Prtiperty Muvt fi�tl� hvelve (12) months
- 6efore March 31 of each year the deduction is sought. v v
Seereversesideforadd'rtionalinstrucGonsandqual�cations. GIBSONCO NTYAUDITOR
� �'�Q
t a�marorton Cbuyer- reSncDwism imside
� lJ.n � /���?/XJ.( l /) �/�
TaF^9"Q'F.� � KeY nunber /�g � desaiptiwi -�
Assessed vahre'oFreal popertY es
MaNi 7, auren[ year
If ro, what is his / her ex3G shan
If name m recdd 6 tliReren[ Na�
Name of rtrongagce or a
Address of rtnrtga9ce or
Nama of aaignea w dM
uMipta Gelow
sbee4 �N'. smm.
N as9gnce (n�mDer aM saee4 �: s+efa, ena <�r cooe)
lipnt own pfoperty in any afher If yes. what
InE"aru? r-� . . r-� _ _
amount
Fde Mark
Form filed with:
Counry Auditor
Counry Recarder
number
1 as of Morigage / ConVact'uWebtetlness unpaid as at I Is ihe app6mnl the sale
date o/ app4ration legal m equilaNe ame!?
❑ Yes ❑ No
If o�med wiN somearre dher than spousa, iMiqte with whom
Is tlre pmperty in 0���: �nuaAy Pssessed
ea� a�oaenv ❑ a,mualy assesud
Mobile Hane PC 61.1-�
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couNrr aunn
ao�a........
pt�",�� \O•""' I —
�1'�9....•$� �� o
Cal.��o. ���y5,31�
2p _ 20 20 _ 20 _ 20 20 _ 20 _
Syiature o( Camb AuEitw Caunry Date (rtanth. daY. Y��I
1 I We certfy urWer the penalry ot perjury that the ahove anG foregoing infortnadon is We an0 cortect aM that the applicant is a resident of IrWiana aM
owner I mntract buyer of the aforementioned property on date appiicaCOn is filed.
�5qnatwe (owne/s fiID neme) /� Date (rnmth, daY• yean
V'r� . I ../1 . 1/ n ,�
lent a0tlress of appGCant (num0er antl street. tily, sbte, eM LP ootle)
�i a. � N - `.�c>�-� � ,�� �f . .�c� �'
�w,�a ey awr ���a ro� w��++er a �.�- z-0.� i
of author've0 person (numOeraM sbee4 �Y. sbte. antl LP rode)
(mmrn, eay, rea�