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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VAIUATION Coun Township Year
S w� J Sute Fwm 43709 (RS / 4�3) � �
� PrescuEed Dy Depanment of Lonl Govemment Finance
INSTRUCTIONS: .JUNF�� �a�006
To be filed in person or by mail with the CountyAuditor of the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 0l the year the deduction is to be eflective,
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the year the de'�ducfton rs��U6e effective.
See reverse side for additional instructions and qualifications. GIBSON C UNTY AUDITOR
Applicant(�n ror ntract Gy r-s
Tauing Dislrid
J��iC,o.r/x Q�`o�
A ssed value of real property as of
March 1, curtent year
on reverse side)
Key number / legal description
QD� Da/o�- dd
Mortgage / Contrad
March 1, currenyytez
as
Record number
Page number � � n0
Is lhe applipnt the sole legal or equitable
owneR ❑ Yes ❑ No
D ��
If �io, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than thaf of applicant, indicate below: Is the property in queslion:
❑ Real Property ❑ Mobile Hmie (IC 61.1-�
�me of mortgagee or contract seller _
`r�/�� a,c.0 �vl,�,� ��vu
Address of mortgagee or contrad seller (number and st2et, city, state, ZIP � �_--
Name of assignee or other owner or holder of mortgage
Address of assignee (numbe�and street, city, state, ZIP
Does applicant own property in any olher I If vP5'"�vhat county? What Taxing Dislrict?
county in Indiana?
2110�0 _"ZZ1a
- Dra�ver NO ................... —
6 m��_ B� fY AUDITOR
Deduction approv �0 0 U 0,
Card NO . .....................
zo �_ � �1�' ��M _ zo
e I� I a I�
Signature
County Auditor
Has this dedudion been requested on
property for wrrent yeaf? (� Yes ❑ No
20
Date
�
We certify under the penalty of perjury thaf the above and foregoing information is true and correct and that the applicants was / were
esident of Indiana and owner of the aforementioned propeRy on March 1, 20
Person authorized by duly executed Power of Atlomey
or by IC 6-1.1-12-.07
Fuli resident address of�ficaM IAddress of authonzed person