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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�. w� J Siate Fortn 63709 (R514-03)
� Prescribe0 by Department of Local Guvemment Finance
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To be �led in person or by mail with the County Auditor of the county whe2 the property is located.
Filing Dates: i) Real PropeRy: During fhe 12 months be(ore May 11 0/ the year the deduction is to be effective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of e year the edu/ ' ffective.
See reverse side lor additional instructions and qualifications. GiBSON COUNiY AUDITOR
Applicant (owne�q/contracf 6uyer-
Tauing Distrid 0
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Assessed vatue of real property as of
March 1, wrrent year
If no, what is
If name on
ieverse side)
Key number / legal description Record number
��77 ��
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6./�/
MoAgage ! Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, c�u�t year ownef? � ❑ Yes ❑ No
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� If owned with someone other than spouse, indicate with whom.
that of appliwnl,
of mortgagee or conlrad seller
Address oi mortgagee or contract seller (number and
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
ZIP
Does applicant own property in any olher If yes, what county? I What Taxing Distrid?
county in Indiana?
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Deduclion approved in the amount of: � Q/ ��G .�
20 � I 20
Signature
�
yl -�:,,/ � y� 4
/ "-' _' '
County Auditor
the property in questian:
❑ Real Property ❑ Mobile Horne (IC 61.
Has this dedudion been requested on
property for current year? � Yes � No
20 � 9 � 20
u
/ We certify under the penalty of perjury that the above and foregoing information is true and corred and ihat the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly execuled Power o( Atlorney
or by IC 6-1.1-12-.07
admress of appficant Address of authonzed person
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