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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�. «• / Stare Form 63709 (RS / 4-03) � � T� - . . y ,
� Presrnbetl by Department of Loral Govemment Finance n ,2 }..-� �'
13 � � � h
INSTRUCTIONS: FEB O 4 ZEO�Mark
To be filed in person or by mail wftb the CounryAuditor of the county where the property is located. /
Filing Dates: 1) Real Pioperty: Dunng the 12 months before May 11 0/ the year the deduction�is to 6e eBective,� ��
2J Mobile Homes assessed under IC 6-1J-7: Between January 15 and March 2,of the.yeai the,deduction/is fo 6e eHective.
See reverse side /or additional instructions and qualifications. �� GIBSON C�: !�� �. ;��; �po '
(owner or contrdct
Taxing Dislnd
�
�b,17-1,7 - c lW
see restnctions on reverse side)
1 �+
Key number / legal description
m r� � � (`\rl`x � �
Assessed value of real property as of
MarcFi 1, wrrent year
If no, whal is his / her exact share
March 1, currenl year
If name on record is difierent ihan that of appliwnt, indicate
mortgagee or conlrect
b_ .
CYSd � � C� lo
Record numb
e
Page number
��
:ss unpaid as of Is ihe applicant
owne�? E
legal or equitable
❑ No
If owned with someone other than spouse, indicate wilh whom.
Is the property
Address of moilgagee orconVaIX seller (number and st2et, city, state, ZIP `�r
Name of assignee or other owner or holder of mortg
DrawerNO ...........:.......
�.
Address of assignee (numberand street, city, sfate, �� �
Card NO. .L!�"�����
Does applicant own property in any other If yes, wh�
county in Indiana?
Deduction approved in the amounf of:
20
Signature
�
0
COUNTY AUDITOR
20 � 20 �� 20 �_
P P
County Auditor
❑ Mohile Home (IC 61.1-�
s this deduclion been requested on
�perty for current year? � Yes � No
�
Date
20
/ We certify under the penalty of perjury that the above and foregoing information is true and correct and lhat ihe applicants was / were
1;esident of Indiana and owner of the aforemenlioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
esitlent address of applicant (/ Address of authorized person
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