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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
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� Prescribed by Department of Local Govamment Finance } € ti �`f �RJ\
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wsrRUCr�oNS: MAY 2 7 20(k�e Mark
To be filed in person or by mail witA the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months be%re May 11 oI fhe year the deduction�is fo be el%tive��
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2'oLfMe�year the•detlartGon�e eHective.
See reverse side /or additional instructions and qual�cations. �� GI°SON COUtJTY r;� 4;ITOR �
Applicant(ownerorcontract - ee striction verseside)
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Taxing Distrid Key number / legal description Record number
/`� / 1 � �'V-v'�� —� Page number �� � 2
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March t, currenl year owneR ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
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If name on record is different than lhat of applicanf, indicate below: Is the property in question:
❑ Rea� Propc�rty ❑ Mobile Hmie QC 61.1-�
ame of mortgagee or contrad seller
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Address of mortgagee or wnirect seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own property in any other If yes, what counry? What Taxing Disirid? Has this deduction been requested on
county in Indiana? property for wrzent yeaRO YesO No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 Q 20 O� 20 � 20 20
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Signature Counry Auditor Dale
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I/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
residenl o( Indiana and owner of lhe aforementioned property on March t, 20
Signa�re (owners (ull name� Person authorized by duty executed Power of Attomey
! or by IC 6-1.1-12-.07
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II resident dress of applicant Address of aulhorized person
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