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�� STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
' � FOR DEDUCTION FROM ASSESSED VALUATION
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PrescnEeC by Department ol Local Govemment Finance
�NSrRUCriorrs:
To be /iled in person or by mail with the CountyAUditor of the county whe�e the property is located. APR 2 6 Zo05
Filing Dates: i) Real Property: During the 12 months before May 11 0l the year the deduction is to be eflective.
2) Mobile Homes assessed unde� IC 6-7.1-7: Between January 15 and March 2 of the yeecthe deduction is to be eHective.
See reverse side (or additional instructions and qualifications.
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GIBSON COUNTV qUD�rnn
Appli (owner or contract bu r- see restrictions on rev side) •
Taxi District � ey number / legal dels�uiit�n� Rec r number ��
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Asse ed value of real property as of Mortgage / ContraU indebtedness unpaid as of Is the applicant the sole legal or equitable
March t, current year March 1, current year owner? ❑ Yes ❑ No
It no, what is his / her exact share of interest? If owned with someone ofher than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
�ame of moRgagee or contract seller
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Address of mortgagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for current year? � Yes 0 No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �� 20 �� 20 � 20 �� 20 20 20
Signature County Auditor Date
I/ We certify under the penalty of peryury that the above and foregoing information is true and correct and thal the applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
ture (o ners full e) Person authorized by duly executed Power of Attorney
or by IC 6-1 J-12-.07
F II r ident a ress ot applicant Address of authorized person
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