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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S- w� J State Fwm 43709 (RS / 4-03)
� P2stnbed by Department o( Local Gtivemmenl Finance "T :^ti "'�— �,
�jj{p�j �� h DULY F.NTE ED FQR TAXATf N
�}L �J Il J.�dbject to final acceptance tor trans er
INSTRUCTIONS: A e day oi File Mark_ _
To be filed in person oi by mail with the County Auditor of the county whe�M�p(rj `�rt�ibcated.
Filing Dates: 1) Real Property: During the 12 months before May 11 the year the deduction is be efl�rtive. � Auditor
2) Mobile Homes assessed under IC 6-1.1-7: Between nuary 15 al�d INarch 2 0/ �1h�deduGt�n is (diWareffeGttye.
See reverse side for additional instructions and qualifications. `���"�P ceI p
GIBSO�V COU� i' ;;�rDnQ� . —
or co�tract buyer -
/y�i'l�� �-/'�/ �`-'
Assessed value of real property as of
March 1, curtent year
If no, what is his / her exact share of interest?
on
Key number / legal description Record number O�
OQ,/ //1/� i�/_o6 Page number
�`/ / (O
Mortgage / Conlrad indebtedness unpaid as of Is the applicant ihe sole legal or equitable
March 1, current year � O� q �� owner? ❑ Yes ❑ No
�
If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
of mortgagee or contrad seiier
of mortgagee or contrad seller (number and st2et,
assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP code)
Does applicant own property in any other I If yes, what wuniy?
county in Indiana?
Deduction approved in the amounl of:
I
20 � 20 � 1�I
� �
Signature
��-ao �7-,�aa- ao�
state, ZIP
❑ Real
�G-a�/
❑ Mobile Hartie (IC Fr1.1-�
Drawer NO .:...:.............
. /,
Card NO. .Ll�^.-...��aZ
>
couNrr a�
20�_ 20 O 20
1 `
County Auditor Dat
20
�es�ea on
Yes � No
We certity under the penalty of perjury lhat the above and foregoing information is true and corred and that lhe applicants was / were
�esident of Indiana and owner of the aforementioned property on March 1, 20
(owners
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
resident address of applicant �/ (� '/'"�' ] Address of authorized person
� a (J b�c oZ �8' 1J G.� �Ct�pl -Y -