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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
�'' �,«. ! State Forrt: a37W (R5 / a-03) .
'� , P25cnCetl �y Depertment of Local Gov¢mment Finance �
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor o) the county where the property is located. n�� � 5 Z005
Filing Dates: 1) Real Property: During the 12 months be(ore May 11 0/ the year the deduction is to tlC ec �ve.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 ot the year tAe dedu�n is to 6e effective.
See reverse side /o� additional instructions and qualifications. ���
GIBSON COUN7Y AUDITOR
Applicant
Disirid
Assessed value of real property as of
March 1, wrtent year
If no, what is his / her exact share of interest?
on reverse side)
Key number / legal description
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MoRgage / Contract indebtedness un
March t, current year
Record number a � G �
vJ
n Page number � �/�
J
as of Is the applicant the sole legal or
owne(? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
If name on record is different than that of appticant, indicate below:
'3me of mortgagee or wntrect seller
�
Address of moitgagee or conUact seller (number and stree ify, stafe, ZIP
Name of assignee or other owner or.holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own propeAy in any other I I( yes, what county?
county in Indiana?
Deduction
Zo s, �
�
Signature _
s the property in question:
❑ Real Property ❑ Mobile Home pC 67.
1�'
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requested on
' � Yes ❑ No
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• � � � ,�• �
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in the amount of:
zo zo o zo
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� � County Auditor
� 9�, aoo. �-
� 4_a9-o5
' We�certify under the penalty of perjury that the above 2nd foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned properiy on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Address ofauthorizzd person