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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
• FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S � � j State Fortn 43709 (Ra / 7607) � � ' ��
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� PresaibeA by Departrtrent ot Local Govemment Finance
INSTRUCTIONS:
�EG 1 y 2�02 FileMark
To 6e filed in person or by mail with the County Auditor o/ the county where the property is located.%%11
Filing Dates: 1) Real Property: During fhe 12 months belore May 11 0/ the year th� educ6 i to �t��flecfi .
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 a, 31 4�Edr uchon is to be eflective.
�' GIBSON OUN f! AU i n�
See 2verse side for adddional instructions and qualifica6ons.
Applicant (owne cont t buyer - see restrictio on reverse side)
Taxing Distrid Key number / legal description Record number ��
OO�—�y/y Q� m� \ Page number
(it� d "(Jl7
Assessed value of real properiy of Mortgage / Contrad indebt ness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year March 1, cu� �yea�� �� pQ ownef? ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is dif(erent than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
�me of mortgagee or conVad seller
Address of mortgagee or contrect seller (numb and street, aty state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sGeef, city, state, ZIP code)
Dces applipnt own property in any other If yes, what county? What Taxing Distrid'? Has this dedudion been requested on
county in Indiana? property for wrtent yeaR� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
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P oA— 4� � P
Signature County Auditor Date
! We certify under the penalty of perjury thai the above and foregoing infortnation is true and corred and that the applicants was / were
. r sident of Indiana and owner of the aforementioned property on March 1, 20
Sign ture wne s full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
F ent ad ss of applipnt Address of authorized person
Y// ` L �
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