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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun shi ar
,. __ � FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (R71 / 6-09)
,,,,, � Presoihed Ey Department at Lo�l Govemment Friance
fNSTRUCTIONS: .
Fartn filed with:
b be hled in person w by mad vnth Ne CounryAUditof or Counry RecoNer o( the counry where the property is bcated.
Fi7irg Dates: 7) Real Pmperty Must file dunrg the year /or which the deduction is soughf. ('q��ty/� �
2J Mobde / Manu(actured Homes rrot assessed as Real Property: Must file dunng the fwelve (12) months �-�(
betore March 37 of each yeur the deduction rs sought. �' 9d�M1��corder
GIBS N UNTY
See reverse side (or additiunal inshuctions aM qualifications. �
qppfpa�n jqwner or �rio-art buyer- see restrictuy�m reve�se side) ^
�������
Mard� 1. riurelrt yrar
tt no, what's his! Mr eract share oi intelest?
r I iega� tl pfm '-' R¢�prti number Pag n
-� a�_ �o0..�9- oa � 0 3
Mortga9e / Contract inde6letlrress unpatl as W MMqaga I Conratl iMebteNress unpaitl as of Is the appfrcanl Ne
Mamh 1. artent year date of eP legal w equilade mmM
� � ❑ Yes ❑ No
H owned wi� 5ortiewie dher ihan spwae. mdrate wRh whom
If name m recoN a Eittueni than Nat ot applkany UMin@ below:
Name of rtnrtgagee ar mntra�Y se4er �
�
P.ddress of �rort9a9ee or mntrad se0er (n nd stree4 , stele, a e
Name o1 assignee w oNer owrrer or htlEer of mMgage �
/
Mtlress ot assignee (number aM stree4 �y, state, and Z/P catle)
Dces epplimnt pm property in any oNer If yes, what count�/1
munry in IMiana?
❑ Yes ❑ No
DvLUClion aaoroved in ihe amount ot
20 I zo I 20
zo _
p�opeMy in Questim: Mnuallyltssessed
ea� Pioperty ❑ nrmuanyAssessed
' �//'
What Ta�dn9 D'aGicl7 I Has Ihis deEUCtion Oeen raquested m pmperty
tor Cu�2nt yea(! ❑
❑ Yes
4UDROR �
��
D�-�,,.���.jo..[..a..���...... �
Card \O. ......�y.�....... '�d`�
I/ We certify under ihe penalry of perjury that Ihe above and foregoing intc
owner I mntracl buyer of ihe aforementlaned pmperty on date application � L�i / oa (' •(�
a Sien?n�.(owners L �> 0
/� '
FW nc atldress ol a nt (num6e� and sbeeG ml; s+ate nd oo0e)
� �i s o�� .� �-��u � f�vt S�s-����
Pn�sm auNw¢eE Dy EWy exenrteE Power af AttorneY w by IC 61.7-12-0.7
Pddress oi auNOraed puwn (numberarid sveeL �; staR. and LP oode)
"ent of Indiana a`W
we.�
�
Date (monN. daY• Y��