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^'no STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmship Year
__ FOR DEDUCTION FROM ASSESSED VALUATION
. sr�e Fam as�os (Rn i �w>
�' ,,,� d P�esrnbed M �ePart�M of lnml GavemmeN Fnatce
il M
INSTRUCTIONS:
Form Ae0 with:
To be fiied in person or by mad with the CountyAuditor orCounry Recader o/ the county where the property is located. q �q
Fifing Dates: 7J Real Property: Must file during the yrear for which Ne deduction is sought. D EC O� {gOl�unry Auditor
2) Mobile / Manufactured Homes rrot assessed as Real Property: Must Re dunng the fweNe (72) months
6efwe March 31 of each yvar the deduction is sought. County Recorder
G`J
See reverse side for additional instructions end qualifications.
Apa� t(ow�erwwnOaCbuyrl'see��+rmr� onreve siie)
'/. _ _ _ .�"/�. . nT �D .r,.. . i GIBSON COUNTY AUDIT
������o�
Marth 1. aa�ent 1Rar
If ro, what is ha / Mr exaC share of interest?
If n3rtre on remrd
mnux+sene�
of mort9a9ce or
-i3-/ -loa-o0o. �i9-oo
��g e/ Contraci intle6letlness unpaid as of Mongage I Contrart �i
Mamh 1, artent year Cate of appGration
Name of assignee w other owner or hdder of mortgage
nearess a� �nee (��� �a �t Gn: s�+e• aro
anyi
Yes
ction approved In the amount af:
20 _ 20 _
NiOitcr
I I We cerbfy uMer the penalty ot
owner I wn4act buyer of the afon
rc �,�a �;n
state, aM LP code)
;' a - � 3 . ��
ha[wuntyt WhatTa�drc,7D'atr
COUNTYAUDROP
20 � 20 _
Caunry
M foregoing infortnalion is 7
date appfiration is filed.
app�bnt (number antl sbeet, aTy, stafe, erM LP ootle)
W
of aulhorized per.,on (numberaid sbeeG �: sbte. end LP code)
/ Recvrd numhrl Page nuMei
� / J- 3 80�3
netlness unpaid as of Is Iha eppfirant the sde
legal or equibWe ovme(1
OC7(� ❑Yes ❑No
;owae. indimte witt, whom
15 the OroPenY in Question: NvwaoYA55es�.d
� Real ProPenY ❑ ���Y �
r,nocae r�me nc s
Mas 4re deduction been reGUesteO m prapeJty
for aumnt yeaR � Yes ❑ I
Dra�ti�er NO.:'��,�„
Card 1�'p,.,,,��C,3
-�.S,C,bp , �`-' ;.
Date (monfi. daY. YaaA
oate (rt,onm. tlay, ye�1
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