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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� ,«. -! State Fwm 63709 (RS / 4-03) . '.� �`, i ; • ` . -.1 . '. . J
'•.�.,._' � .�:�.�, ,`
PresaiDed by DepartmeM o( Laal Gtivemment Finance �
INSTRUCTIONS: " ' � "''`- '� �"�' " � e'Mark
To be lled in person or by mail with the CounryAuditor o/ the county whe�e the property is Iocate�E6 2 1 20�Jd
Filing Dafes: 1) Rea1 Pioperty: During the 12 months be%re May 11 of the year the deduction is to 6e eflective.= :
2),Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and.March 2 0l th���ion is to be eNective.
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR . �� '
or contracf buyer
Taxing
��CP/!�' �2
Assessed value of real property as
March 1, current year /
no, what is his / her exact share of interest?
It name on
on reverse
I�ey number / legal description Record number O�
/
O� / �� � � _ �,A Page number / d'
(� Y-� �
Mortgage / Contrad indebtedness unpaid as of Is lhe applicant �thj� ole Iegal or equitable
March 1, current year I� y� p 0� ownef? I�S,Yks ❑ No
//. 3 0 0� , .,
lhan ihat of applicant, indicate below:
of mortgagee or contraG seller
If owned with someone other than spouse, indicate with whom.
Address of mortgagee or contract seller (number and street, city, state, ZIP
Naine of assignee or
Address of
owner or holder of mortgage
(numbe� and st�eet, city, state, ZIP code)
❑ Mobile Home (IC G1.
Dra���er NO.. v�.-.l.a•.�
Does applicant own propeAy in any other If yes, what county? ��
county in Indiana? CaCd \'�.
�� , L 1�1 _/J i/ /—, COUNTY AUDITOR
Deduction approved in tJ/.e amount of:
20 _Q� 20 �_ 20
� P Q
Signature
20
County Auditor
�
20
Date
n requested on
ir?� Yes� No
20
We certify under the penalty of perjury lhat the above and foregoing information is true and correq and that the applicants was / were
�esidenl of Indiana and owner of the aforementioned property on March 1, 20
full
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
resident addrEss of �applicant � �Address of authorized person