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! i 4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'i'�; FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
�J • S�ate Fwm 43709 (R6 / 5-06) � � 4 �
� M• Prescnbed by Department of Local Gmemment Finarxe �
J1.
iNSrRUCnoNS: JAN F;i�?��1$
To be filed in person o� by mail with the County Audito� o/ the county where the propeRy is located.
Filing Dates: 1) Real Property: During the 12 months be%re ,lune 17 of fhe year the deduction is to be effect�a� ,Q������+++!�!�!�"""���...
2) Mobile Homes assessed under IC 6-1.1 J: Between January 15 and Maroh 2 of lhe yeGIBSON COU� A��O�ictive.
See �everse side fo� additional instnictions and qualifications.
contiact buyer- see
U�
on reverse side)
number / legal description � Record number
Page number
o� - - O -G�e D-
Assessed value of real property as of MoRgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year March 1, current year owne(? ❑ Yes 0 No " '
�J . .
If no, what is his / her exact share of interesi?' I( owned with someone other than spouse, indicate with whom.
If name on record is difterent than that of applicant, indicate below: � Is the property in question:
ot moAgagee or contrad selier
Address of mortgagee or wntrad seller (number and s'--"—"• -!^�� �� .
Name of assignee or other owner or holder of mortgag�
Address of assignee (num6er and st�eef, city, state,
Does applicant own property in any olher I If yes, what
county in Indiana?
Deduction approved in the amount
❑ Real Property ❑ Mobile Hane pC 61.
O�
�-50,-c�o-�=
:questea on
❑ Yes 0 No
20 �_ 2� 20 _� �, ^ �,.,� ,.y `r �
� ..�.n 1C�1 �[io� �
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Signature (
We certify under the penalty of perjury that the a ts was / were
esident of Indiana and owner of the aforementic.. _._
name)
'ull resident address of applicant
1o33a s. �sv� iJ�,,�,�S.S�.
Person authorized by duty executed Power or Huu��iey
or by IC 6-1.1-12-.07
ofauthorized person