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.i T
Year
STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION i
b !
,,,R.,.i.,41,,,,,,,,„• Stehe Form 43709
Prescribed by Department al Local Government Finance I
File Mark
INSTRUCTIOPVS To be fed in person or by mall FEB 8 20
i ri,_:TC;aad-7ito'ff h oiy Auditor
t
Filing Oafs, Form thJ w;
st he completed and dated in the cafenda-year for hich the deduction is sought ,
Must be filed or postmarked with the County Auditor or County Recorder of the county wh_. h.', rope/rt_‘zz...cp.,.. ."4, ,,,,,,,,,,,Race-do-
COUNTY located on or before January'5 cthe ca! er end yea-in v.hiab the p-operly taxes are first dAf..,„Q,
...III COUNTY AU ,
See reverse s,de.for add,tione"instructions and quatifice.'.ianS
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-iiisevini)C sn ot,___ i Rccrpr
umber
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,.._,..s.„....,..,„,,,_, _ma'pro7aat ns cf i r.terti,-.),-J-s./Contrast indsocanness•_,-nre a-as o 1..lontgmte/Contra,:ie.:fetter:I-ass unpaid-as of 1 Is trasi Op Iic—it th,--,-Z-,7,:- -----'
assass-enI date ncraisat t,a. assessment date current yam- data of acpIistatien i lope'or o ••.abIe a: e m -7
3
•, 47/0. co e, 1 yes [---T N.
If r cTip.tratislirrsTriierexaat share of iota-e712 I If ov.ned v.itn sorreone ott'Ser Dan spouse indicate v...tin whom
.-1-f na-e on reCip7d7Sir d ffereat tiepin tnat of amp'cant i7r.4 trate bin'o, I, n ()rope cy-m quest nn Arlrl.IaIly Ass,,ssed
- Assessed
...to
- 0 orne(IC 6-1.1-7)I
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-01-h.7-e-cet se'is-
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7,,,iii-r7-;s;ht,0--..zsoett,0:C-clltr. III.;I:e..-(r',73.t.--.-,a-7,J streinif mt./ sIsIe.85.ZiF,Ccri-T-II-------- — —
FEB $ 2022
rs:-.3-,ec;el5-6,g--,,,e.0-cc,:...,,,,,a-hede-- ' - _
-7,1-1-rt-- Ir.-r;IIIIIgIii:II-C-1.7,(rI,rrt,:,-71,72 2,SI'ee: c _,..i5- 95 GIBSON COUNTY AUDITOR
Dii-.:as ,---:''T7...: 7(7,,.'""p'OpOrt/i, y I II ye re0On 7-6_,-:'1--..?...,,s'..ed i If ye,s state amopirit of dinneetion
Othe,C,J,II./ ,Yes I r - ___,
irl II-II-I ar-o? t_I k-t-ol:: '`,..,:l I Li No ! '
A person is not entitled to trns de.cruc..tic w•co, t of indebtedness that is recorded in the county
recorder's office(including any home e .";e)t at 's the basis for the deduebon.
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6)eOTitt27.edacp,ove'd the arr ,r."t of
i 20 , 20_ 20 . 20 ,
20
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SToriej....pie of Cr.tunt Jditor zezjef_,..„--,__e__,..-4......„..... i CC,-rry I Date(7-c..,:, dai y.,-,--3')
I 'We cc- •= under 'cc p nal of petju'y that the above and fo,egoing information is true and correct and that the applcant is a resIdent of Inc:Lana ando i
t yer i t aforementioned property on date appi cation is filed
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. ...,,,eser: remeer a-d sIreet oti„, Vote asd ZIFI nesiatI --
If 7•5 5 fOCI Li 0 weri 54",We.__.7.4.. ..„„_ ..„___....„„____ — _7.--„-- _
FIE'S:,a.:tir-Pri-zOd bi Cu",exen:ted P7...ser of Attorne,or bi IC 6-, 1-12-0,7 I Date frriantn day
,
`"aaor,za-,.d penis fremOsr and Street citi, state arc Zh'° ,:.., I-------------------------- ,
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The pe,,,,Oft,SS for perjury can include imprisonment up to trio and a ho'f years and a fine not to exceed S/0,000