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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FQR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�. ! Siate Fwrt: 43709 (R5 / 4-03) � �
41� T
� Prnscn�ed Dy Department ot Loral Govemment Finance N �
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wsrRUCnorvs: JUL 2�`e7��
To be filed in person or by mail with the County Auditor of the county where the property is located.
Fi/ing Oates: 1) Real Property: Dunng the 12 months before May 11 0/ the year the deduction is to be eH�ijpue� ��
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year ��ie de�iction o be effective.
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR
Taxing
(owner or contract 6uyer- see resMctions on revgrse side)
. _ _ . �i J\ ._
Key number / legal
Record number
Page number
lV lo " Cc° O ��
Assessed value of real property as of Morfgage / Contraci indebtedness unpaid as of Is the applicant...IIIt___h,,,e,,, sole legal or equitable
March 1, current year March 1, current year owner? �es ❑ No
� i00
If no, what is his / her exact share of inierest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
.me of mortgagee or con[rad selier
� ���� � �
Addressoi mortgagee contract seller (number and sfreet, city, state, ZfP
Name of assignee or othefowner or holder of mortgage
Address
{numoerano street, aty, state, LIF'COtlE)
Does applicant own property in any other If yes, what county?
county in Indiana?
Deduction approved in the amount of:
�
Property ❑ Mobile Hmie (IC 67.1-�
Dra�►�er NO...D,�~, .�� �[T/
What Taxing DistricY Card 1�i0, I
COUNTY AUDITOR
20 �'� 20 �'L 20 I 20
P �
County Auditor
20
Date
20
' We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
'esident addressof
sz � � 1�/'a��,
Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person