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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR OEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
Siata Fwm 43709 (RS / 6-03)
PrescnDed by Department of Loral Govemmem Finance
wsrRUCrioNS: JAN 1 9 Z���Ma�
To be rled in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0/ the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7: Between.January 15 and March 2 0/ the'y� jhe �y�tion is to be effective.
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See reverse side for additio al instructions and quali�cations. GIBSON COUNTY AUDITOR
a�- i�-i�- ac, � c�l ��� cb� .
pl nt (c�v�� or contract bu e- se� reatnctions on re ers side) ,_
Assessed value of real property as of
March 1, current year
Ii no, what is his / her exact share of
Key n / legal description
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Mortgage / Contrad indebledness
March 1, current year
Record number D�
Page number � a �
as of Is the applicant the sole legal or equitable
owner? ❑ Yes ❑ No
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�owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
of mortgagee or contracl seiler
Address of mortgagee or contraIX seller (number and sf�eet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, cify, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid?
county in Indiana?
Dedudion approved in the amounf of:
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Signature
COUNTY AUDITOR
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_ County Auditor
s the property in question:
O Real Prooertv ❑ Mobile Home (IC 61.1
Has this deduction been requested on
property for current year?� Yes❑ No
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Date
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We certify under the penalty of perjury lhat 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
t e (owners full me)
sident address o applic
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Person authorized by duty exewted Power of Attomey
or by IC 6-1.1-12-.07
authorized person