Mortgage_West (3)'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ovmshi Year �
__ FOR DEDUCTION FROM ASSESSED VALUATION
• State Fam 93709 (R11 / 6-09)
� presoibed by Deparlment al Local Gwemment Fitw�ce
� File Mark
INSTRUCTIONS: MA �
To be lled in person a by ma�7 wdh the CounlyAuditor or Counry Reoorder af the to�nry where fhe property is bcated.
Filirg Dates: 7) Real PmpeRy: Must file dunng Ihe year for which the deduction is sought. unry A ditnr
2J Mo6Be / Manu(ectured Homes rat assessed as Real PropeAy: Must file dunng the fweNe (12) months
befoie Ma�ch 37 of each year the deduclion is sought. unry Recorder
See reverse side loraddifional instruclions arrd qualifications. GIBSON
Apqfjc�t (owneror mwaa pyyer- see m rerxrse vde) .. �
T" District � Key ruunber / legal Oescription Recortl numbel Page numbel
atv- a.-o -tioa�-ooy. �30 -� g a�� i4
Asesse0 vaNe d mal P�W�Y as W Monga9e / Contrarl inde6tedness unPaid es of Mort�age / ConvaU irMebiedness unpaitl as d Is Iha ePPGfsnl lhe
Ma�di 1, arrrnt yrar A1amh 1, artent year date of appfimtion legal w epWtable ameR
� (� ❑ Yes ❑ No
If ro, wha� is his / Mr e� share of interest? 1/ ovmed wiN someone r Ilw� sWuse. iMifate wiTh whom
If name m 2rntl is NRerstl tlwn that ot applican; i�Min[e 6elaw. Is C�e Property in puestion: MnuaM Asessed
eal Roperty ❑ Mnually A55es�
MoW'le Flane IC G7.7=
Name ot nqrtgagee w mntraU seller
S.
Addmss of mort9a9ee or contran se0er (num6er aM stree ciy, sfate, aM ZfP code)
Name of assignee w other awner a hdAer af rtqrtgage
AECress of assignce (number aM stree4 �Y, slafe. entl ZIP a
Does applinnt own poperty in any aNer If yes,
munbminAiana? 1-"1 .,__ I-1 .�_
v � ��-
EWion Deen rc9ursted m P�nY
� ❑ res ❑
COUNTY AIIDROR
Deaucvon aPC�'�'vi ihe armunt ot ll I' a 11' C I' l�i Q... .((�� J.� .....
zo_ zo_ zo zo zo. Card i1'O. .......I �
.... ........
SignaWre Co NAu�itw . Counry ��1'�W, v`l
i/ We certify under Ne penalty oi perjury ttiat the aDOVe and foregoing infortnation is We and corteG anC Nat Me apqicam u u���ti�,., ... ..._.__ .
owner I contracl buyer' f the aforementioned property on date application is filed.
(owrers N2na ) Date (nunfi. daY. Y��
� ^ .
V `� .
/� o
PerSOn :
Address
ss ot a t(numher antl s7ree4 a�}: �te, arM LPoode)
�o�J��K n� �;�.<T��
Dy Otdy executed W Aitwney or by IC 61.7-72-0.7
P�
a
(monfh. EaY. Y��
\�
