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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
,• / State Fwm 63709 (RS / d-03) � . _ T
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P25cribed by Department of Loral Govemment Finance
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INSTRUCTIONS: MAR .1Fi� �
To 6e filed in person or by mail wilh the County Auditor o/ the county where fhe property is located. �
Filing Dates: 1J Real Property: During the 12 months before May 11 olthe year the deduction is to be eff t!'
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year t��UOi4�ivrs�o be e8ective.
See reverse side fo� additional instructions and qualifcations. G�BSON COUNTY qUDtTOR
Applicant
Taxing Dislrid
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Assessed value ofrealproperty
March 1, current year
I( no, what is his / her exact
- see
otinterest?
If name on record is different than that of
mortgagee or contrad seller
reverse side)
Key number / legal description Record number �/
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�Ql/ O� I /�_D�\ Page number ��
l/ 11.5�_ o "
MoAgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year ownef? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
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indicate below: Is the property in queslion:
O Real Property ❑ Mobile Home QC G1.1
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Address of mortgagee or contract seller (number and st�eet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
(number and st2ef, city, state, ZIP code)
Does applicant own property in any other I( yes, what county?
county in Indiana?
Dedudion approved in the amounl of:
20 �.
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Signature _
20 _Q $
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3� i �a� � �9�,8ro' �
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(i�'��' ` O Ip —�/ S � On requested on
� °`af?�]Yes❑No
COUNTY AUDITOR
20 20 20
P
County Auditor
20
Date
20
We rtity under lhe penalry of peryury that ihe above and foregoing information is true and corred and that the applicants was / were
e de Indiana and owner of the aforementioned property on March 1, 20
at (o {n+e�rs f�ull nam�e")' Person authorized by duly executed Power of Attorney
, Q.(d.�LU . 1' . � A///.�. or by IC 6-1.7-12-.07
����n� Atltlress ot authonzed person
6 � �.�, �126 ?�
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