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'�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ovmship Year
� FOR DEDUCTION FROM ASSESSED VALUATION
� • Sfate Fwm 43709 (R71 / 6-09)
�' a�. � Presrnbe0 M�G�reN of LxW Govemment Finatxe
il
INS7RUCT70NS: F
To 6e filed in person or by mail with the CounlyAudi[or or Counry Recorder o/ the county where the property is located.
Fd'ug Dates: 1) Real Property Must fife dumg the year for which tha deduction is soughL �� County Auditor
2J MobRe / Manufactured Homes rrot assessed as Real Property: Must fife dunng the twelve (12J mor� V 9 Z County Recorder
before March 31 of each year Ne deduction is sought.
See ieversa side (o! additional insfrucGOns and qualifiwtions. C���
MM (owneruoontrarl6uyer- re9fictionsm2verseside)
� f GIBSON COUNTY AUDITOR
T' Distria Key / kgal desaiption Rernrd numhet Page numbni
3_i - aB� - bo . s �- o� y �-� < a- ��y9
vaWe d reai poperty as W 'Mortqage/ Contra�t udehtednes unpaid as of Mortgaga / ConraC 6WebteOness unpaid as d Is Ne appfrant fha sole
1. ameN yrar Mard� 1, artent year date o( aPPtiretion legal or eQUitaWe ownM
oZ D D D U l-1 ves ❑ No
If ro, whal ls his I trer esac[ shara Of inieJest9
tt nart�e m remtl is 6ftemnt itan ihat o( aPP�C
Name of mortgagee or contrarl seller �/ �
�
Addrea of mart)agce or rontracl seller (n and sfreet ��}: sb�.
Name oi assignee w other owner or halder af mortgage
waa o� asv9nee �numcerarm suee; a�
�T �E i3 -
Dces appli�nt own pfoperty in any olher
a��a m u,� �u�c or.
IF ovme0 vri� someone dher sPOUSe. indicala with wlu
Is ihe DroP�Y in Questic
❑ Real RoPenY ❑
':, aw ur coae)
-�0 7.4�3RC..
� If yes, wha[ munt�R " What Tarin
COUNTY
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SignaWre of Co�mbAUd'rtor Caunb Data (rmNR �S: Yea�
i7
I 1 We certfy u�er Ne penalry rjury that 6ove and foregoing infortnation is true and cortea and Nat the applinnt is a resident of IMYana a�
owner I mntrac[ buyer of the atorementim perty on date appfiration is filed.
1_ �Ure e(s /ull reme) Data (monlh, daY. Y��
/� �
WI resitlent aCEress of appOdnt (numbe�aM t, tiry, state, erN LP oode)
Sa-G�c /as�5 f�lf Sw ��639
P�.,on author�d by duty exea��ed Powei ol Atmrtiey ar by IC 67.7-72-0.7 Da1e (monlh. tlaY• 1'ea�
AEtlress o( autharaed person (numDesarN sveeS uN, sbte, antl ZIP cnde) .