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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Townshi Year
: w� J Sute Fortn 63709 (RS / 4-03) � 7
� PmscnDeE Ey Department ol Locai Govemment Finance :
wsrRUCr�oNS: FEB � 7�005
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To be filed in person or 6y mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 monfhs befo2 May 11 of the year the deduction is to be el(ec�a� ,Q
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year th€ dedr(p[ron is g��ctive.
See reverse side for additional instructions and quali�cations. GIBSON COUNTY
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Applicant (owner or contract buyer - see restrictions on reverse side)
Taxing Districl Key n mber / legal description Record number
Page number ^Q
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as ot Is the applicant the sole legal or equitable
March 1, curcent year March 1, current year ownef? �,�es ❑ No
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If no, what is his / her exact share of interesl? If owned with someone other than spouse, indicate with whom.
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If name on record is different lhan lhat of applicant, indicate below: the property in question:
I Property � Mobile Home (IC &1.1-�
me of mortgagee or contraIX seller
Address of mortgagee or ntrad seller (number and st2et, city, sfate, ZIP
Name of assignee or other owner or holder oi mortgage —___ _ • ._ -
Address of assignee (number and street, city, state, ZIP code) ,
Drawer NO.. Q� • •���0
Does applicant own property in any other If yes, what county? What Taxing Dis Card NO . ......................
county in Indiana? �
COUNTY AUDITOR
Deduction approved in the amounl of:
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Signature County Audilor Date
/ We ceAify under the penalty of perjury that the above and foregoing information is true and correct and that the appiicants was / were
residenl of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners full name) Person authorized by duly executed Power of Attorney
' or by IC 6-1.1-12-.07
Fu resident a ss oi appli t Address of authorized person
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