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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
� FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
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� P25cribed by Departmem of Loral Govemment Finance �
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To be filed in person or by mail wrth the County Auditor of the county whe2 the property is located.
Filing Dates: 7) Real Property Dunng the 12 montbs 6efore May 11 of the year the deduction is to be enective. �
2J Mobile Homes assessed under IC 6-1.1 J: Between January 15 and March 2 0/ the year. Me d�ducGan is to be eHective.
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See 2verse side for additional instnrctions and qualifications. GIB50� COUN7Y P.UDITOR
Appiicant ( w r or contracf
Taxing Distrid Key number / tegal description ecord number
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Page number
Assessed vatue oi real property as of MoAgage / Contract indebtedness unpaid as of Is the applica t e sole legal or equitable
March 1, current year March 1, current year � Od� p Ob ,� owner? es ❑ No
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If no, what is his / her exact share of interesl? Ii owned with someone other than spouse, indicate with whom.
If name on record is different ihan that of applicanl, indicate below: Is the property in question:
Property ❑ Mobile Hmie pC Cr1.1-�
me of mortgagee or conlrad seller
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Address ot mortgagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and stieet, city, state, Z!P code)
Dces applicant own property in any olher If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for currenl yeaf?0 Yes❑ No
1_� t C�^_ COUNTY AUDITOR � � C Q
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De uction approved in the amouni of:
20� 20_Ql�_ Z� 20 20 20 20
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\ Signalure County Auditor Date
We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
'e;u (own�ull name) Person authorized by duly executed Power of Attomey
\ or by IC 6-1.1-12-.07
'vit address o( applicant Address of authorized person
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