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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Yea
•�w� J State Fwm 43709 (RS l 4-03) �
� PrespiDed by Depanment of Local G6vemment Finance � 6�
INSTRUCTIONS:
To be filed in person or 6y mail with the County Auditor of the county where the property is located. AP R 2 F�le�ark
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Filing Dates: 1) Real Property: During fhe 12 months before May 11 of the year the deduction is to be eflective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year t deduction ' be eRective.
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See reverse side for additional instructions and qualifications. Q U
� �� � �6 � � �� _ �' 377 . �IBSON COUNTY AUDITOp
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Applicanl (ow r or contract b r- see restnctions on reverse s e) ^
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Taxing fid
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Assessed value of real property as of
March 1, curtent year
no, what is his / her exact share of
Key number / iegal description Record number
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Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owneR ❑ Yes ❑ No
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owned with someone olher than spouse, indicate with whom.
If na on record is different lhan that of applicanl, indicate below:
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�e of mortgagee or conlract seller
Address of mortgagee or contraIX seller (number and str , city, state, ZIP
Name of assignee or other owner or holder of mortgage
(numberand stieet, city, state, ZIP
Does applicant own property in any other I If yes, what county? What Ta
county in Indiana?
Deduction approved in the amount o(:
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Signature
COUNTY AUDITOR
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County Auditor
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Is the property
❑ Real Proper
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ShErrJ ���;r
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❑ Mobile Home (IC Crt.t-�
� U 0 � - �(o �C� �quested on
� Yes� No
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We certify under the penalty of perjury that the above and foregoing intormation is true and corred and that the applicants was / were
�esident of Indiana and owner of the aforementioned propeAy on March 1, 20
full
D.
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Address of authorized person