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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
'•.� N� ✓ State Fwm a37pg (R5 / a-03)
� PrescriEed by Department ot Loral Govemment Finance � � �
INSTRUCTIONS: � � � File Mark
To 6e filed in person or by mail with the CountyAuditor of the county where the property is loc�{��� 7
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year fhe deduction i�+t8`b eeflec�rQv�s
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to be effective.
See reverse side for additional instroctions and qualifications. �a� ��
� GIBSON COUNTY AUDITOft
Applicant (owner racybuverr see 2sfdellAns on fevers�lsidel � � � i7n �� �- —I
Taxing Distrid '
�`�"
Q� �
Ass ssed value of real property as of
March 1, current year
If no, what is his / her exact share of interest?
name on record is different lhan thal of
of moRgagee or contracl seller
of mortgagee_or contran.�^��—'—
assignee or
of assignee (
Does applicanf own prc
wunty in Indiana?
ZO
Signature
number / legal
Record
O/� �— W�� /' �� Page nu \ �Jg y
Mortgage / Contrect indebtedness un aid as of Is the applicant the sole legal or equitable
March 1, current year q�� �pp ownef? ❑ Yes ❑ No
c�S�OZ�
It owned with someone other than spouse, indicate with whom.
indicate below:
�
�
Drawer N�............
a�x,� -�39:�
����v 1
. -� �., : � What Taxing Distrid?
approved in the amount of:
20 _�_g_
V
COUNTY AUDITOR
20 � 20 20
�
County Auditor
'roperty ❑ Mobile Home QC fr1.1
Has this deduction been requested on
property for current year?� Yes❑ No
20
20
We certify under the penalty of perjury that the above and foregoing information is true and corred and thal the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Signature
�
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
authorized person