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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
:��� J Sute Fortn 43709 (R5/ 4-03) �
� PrescnDed Oy Departmen� ol Lotal Govemmen� Finance
INSTRUCTIONS: MA�e ��` 2005
To be filed in person or by mail witA the County Auditor of the counry whe�e fhe property is located.
Filing Dates: 1) Real Property: During the 12 months be%re May 11 of the year the deduction is to be elfecfive.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year tAe deHn�wn is��ffective.
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See reverse side for additional instructions and quali�cations. pIBSON C UNTY AUDITOR
or cont ct buyer- see r
���� �
�ed value of real property as of
1, current year
no, what is his / her exact share of interest?
on reverse side)
Key number / legal description
,
Record number ^�
Gj"
DD — ��i� �}� �il Page number
uv c/ /
MoAgage / ContraIX indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owneR ❑ Yes ❑ No
33 a�U
If owned with someone other than spouse, indicate with whom.
If name on record is different than Ihat ot appticant, indicate below:
��ne of mortgagee or contract seller ��
of mortgagee or contract selier (num � c�tv stale, ZIP
� — —' -•-.,o '
ot assignee or other owner or holder ot
Address of
(number and street, city,
Does applicant own property in any other I If y
county in Indiana?
Ueduction approved
20 O �
Signature
in the amount of:
20 Q'� 20
P
certify under the penalty of perjury
lent of Indiana and owner of the af�
name�
of
s the property in question:
❑ Real Property ❑ Mobile Home pC &7.1
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�
� � .�� �
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aoo� - ar�s
uested on
I Yes� No
;s was / were
iey