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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�'. w� / State Form 63709 (R5 / 6-03) .
� Prescn�ed by Departmem of Local Guvemment Financa , �
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INSTRUCTIONS: File Mark
To 6e filed in person or 6y mail with the County Auditor of the county where the property is located. F E B 1 9 2�04
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be eHective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 2 of ttie year the deduction is t�be effective.
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See reverse side for additional instrucfions and qualifications. ��I �iJ��
� � " GIBSOPI COU;�I v qUDITO�
Taxing
(owner or contract�9u�er - see �estnctions on
number / legal
Record number
r.
QQ1 1,. lti1'�P1/t� O�� Page number �/
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Assess value of real property as of MoRgage / Contrad indebtedness unpaid as of Is the applicani the sole legal or equitable
March 1, wrrenl year March 1, cunent year owne(? ❑ Yes ❑ No
If no, what is his / her exact share of interesl?
name on record is different lhan ihat of applicanl, indicate below:
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If owned with someone other than spouse, indicate with whom.
Is lhe property in question:
❑ Real Roperty ❑ Mobile Home
�me of moAgagee or contract seller
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Address of mortgagee or contraG seller (number and st2et, city, state, ZIP -- - D'/
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Name of assignee or olher owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code) �
Does applipnt own property in any other If yes, what county? What Taxin Has lhis dedudion been requested on
county in Indiana? I property for wrrent yeaR � Yes ❑ No
20
Signature
approved in the amounl of:
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COUNTY AUDITOR
20 �Z 20 �� 20
V
County Auditor
20
Date
20
certiy under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
'ent of Indiana and owner of the aforementioned property on March 1, 20
of
I
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
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of authorized person