Mortgage_Lamey (15)�
—"'� STATEMENT OF MORTGAGE OR CONTRACT���N�S Coun Township Year
• FOR DEDUCTION FROM ASSESSED VALUA N �..�
� State Fortn 43709 (R77 / 6-09) �/
�' r Presaibetl M Departrtertl o11n21 Govemnrenl Friance
� File Mark
wsrRUCnoNS: FEB 2.6 2013 F«,�m�a�u,:
To be filed in person w by mail vriN fhe CountyAuditor or Counry Recorder o� the county where the propelfy is located.
Fil"mg Dates: 7) Real Property Must !ile during the year /or which the detluction is so � Counry Audiinr
2) Mo6Be / Manufactured Homes rrof assessed as Real Property: Must � (12J rrwnths � Counry Recorder
betoren4arch9loteachyearthadeductionissought GIBSONCOUNTYqUDITOR
See reverse side /or additional instructions and qualfications.
AppGwm ( a contrart buyer - see rn reverse siYe)
�i_,. � w 7'Y� ,.. � ., �f � -
As$�sed �rWue cf rnal poperty as d Mort�age
M�h 1, qrrerrt year Martl� 1, i
K fq. N{IaI �5 �15 / �IPl BYdfl S�INB O( NiCRS{�
5
tt name m 2md's tlifterenl Uun Na'�.
Name of mat9a9� n mpV�t� uAer
rmrtgagee or mntract seAer (number aM stree4 cilY, state, aM ZIP code)
oi assignee w oticer owner w hdder ot rtartgage
PdE2ss ol assignee (numDer eM snre4 uty. stete,
Does e
mun�'
20
ranl wm property in any other
�Eiana?
❑ Yes ❑ No
approved in itre amount of.
_ p
�f CoimN AuOitor
Reoortl numbu
�/ �- aa � '�
as W Mwtgage / Contra�Y indeb[edrress unpaiE as M'
dale of appGfatbn
$0(IILWIIB
It yes. whal county.+ I What Ta�dng Distr'u1?
COUNTVAUDROR
20 _ � 20
Caunry
20
S�O�SC.
equilade ownnYl
] Yes ❑ No
�s me woaero i�,u�,: amuem wssessca
❑ Rea� Properry ❑ amuany wssessed
_—' � / /1$L�1(Jl/\ �f, _NCJ
I � _jHr
�`� '��� �' � . q �
�3
_ IVO
�_ � �_
�v, Yea�
I/ We certify under Ne penalty of perjury that the above and foregoing intortnation is We and cortec[ arM tha[ the appiirant is a resident of Indwia and
owner I contracl buyer of the atwemeMionec�.p�operty on da[e application is fileG.
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Prlsm auU�a¢eO by dWy exewced Powe+
m
Pddress W auC�u'ved person (number anG slree; city, slala, and ZIP tode)
t �'it/ � ?l 3
oace �,nonm, aar,
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