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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
= FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S / Sute Fortr. 43709 (RS / 4-03)
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� PrescnDed by Departmenc of Loral Govemment Finance
INSTRUCTIONS: ile Mark
To be �led in person or by mail with the County Auditor o! the county where the prop y s�a� �.�
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0( the year the de uct�o� �s��e h
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2.o�Yhe year the deduction is to be efiective.
See reverse side for additional instructions and quali�cations.
M 5 2006
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Applicant (o� er orcont�acf buye�- see iestnctions on revers ide) GIBSON C6UNfiY p�
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Taxing DisiriG Key number / legal descr ption Record number O�
� 'l�— D // O _ Page number � � �'
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Assessed value of real propert as of MoRgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitabie
March 1, current year March 1, wrrent year ownef? �Yes ❑ No
O O
If no, what is his / her exact share of interest? ii owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicanl, indicate below: is the property in question:
.. �. ai Property ❑ Mobile Home (IC G1.1-�
�me of morigagee or contr:
p,� � �. 3�� ����
Address of mortgagee or cor
Name of assignee or other o� � Ii � � �� � ^ �� �G �� �
Address of assignee (numbe /� [� _ 2�,1 � I
v J � j
Does applicant�own property !as this deduction been requested on
counfy ir Indiana? roperty for current year? � Yes ❑ No
`s�, i�-a
Deduction approved in the ai
20 �� 20 O� 20 �9 20 20 20 20
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Signature Counry Auditor Date
We certiy under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
reside Indiana and owner of the aforementioned property on March 1, 20
Si n e ner /WI n e) , Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
'resident address o applicant ,� 1,� �. Address of authorized person
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