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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�' ' FOR DEDUCTION FROM ASSESSED VALUATION P Year
Coun Townshi
� �M� ! Sute Fortn 43709 (RS / a-03) . , � , .
PrestriEcd hy Department of Lotal Govemmen� Finance � g
� �/
INSTRUCTIONS: II^' O 5 ZOOE File Mark �
To be filed in person or 6y mail with the CountyAuditor of the county whe�e [he property is I�C9Y8d.
Filing Dates: 1) Real Property: During the 12 months be%2 May 11 0/ the year the deduction is to be e/fective.
2J Mo6ile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 oY�th� ye@r,t�e,deduction is to 6e eNective.
See 2verse side for additional instnictions and quali(cations. GIBSON C� TY AUDITOR
(owne�o�nt}act buyer� see
Taxing Distrid
Assessed value ofrealproperty
March 1, current year .
If no, what is his / her exact share of interest?
on
Key number / legal description
� l 6 -bOSa� �
MoRgage / Contract indebtedness unpaid as
March 1, current year
Record number
Page number
Is the applicant the sole legal or
owneR ❑ Yes ❑ No
bDa I
If owned with someone other than spouse, indicate with whom.
If name on record is different than ihat of applicanl, indicate below:
�me of mortgagee or conireIX selier
Address of mortgagee or conhact selier (number and et, 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 county?
county in Indiana?
Deduction approved in the amount of:
20 U 1 � 20
� P
�
- - �3
Is the pro - rty in qu tion:
❑ Real Property ❑ Mobile Home (IC 61.1-i
�`
Dra«�erNO.a.Q..Q�p •3�3�7uestedon
� '� �� �Yes❑No
Card NO . .....................
couNrY aui
20 0 20 20
P
County Auditor
20
Date
20
We certlfy under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
full name)
Person authorized by duly executed Power of Attomey
or by IC 6-7.1-72-.07
of applicant IAddress of authorized person