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,e��A� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS �
's'�; FOR DEDUCTION FROM ASSESSED VALUATION Coun( Township Year
' . «. / State Fwm 43709 (R6l 5461 �
� Presaibed by �epartment of Loml Gwemment Finarice
INSTRUCTIONS: NOV O p��
To be tiled in person or 6y mail with the CountyAuditor ol the county where the propeRy is /ocated.
Filing Dates: 1) Real Property: Dunng the 12 months 6etore June Il o! the year the deducUon is to be e 6ve.
2) Mobile Homes assessed unde� IC 6-1.1-7: Between January 15 and March 2 of the year�dedl.r�to be effective.
See reverse srde for additional instnictions and quali/ications. , GIBSON COUNTY AUDITOR
(owner or contract buyer- see restricfions on reverse
Taxing Distrid
0 o c� - r�a b$-
Assessed value of real property as of
March 1, current year
what is his / her exact share of interest?
I( name on record is different than
of moRgagee or contrad
Key number / le
�G-//-��
Mortgage / Contrad ii
March 1, current year
indicate below:
e
cription ' Record number
cb�aoe cb27
Page number
of mortgagee or contract seller (number and st2et, aty, state, Z/P
Name of assignee or other owner or holder of mortgage
Atltlress oi assignee (number antl st2et,
unpaid as of I Is the applicant he sole legal or equitable
owneR s ❑ No
with someone other lhan spouse, indicate with whom.
Does applicant own property in any other If yes, what county? What Taxing Di:
county in Indiana?
Deduction approved in the amount of:
20
Signature
20 0
COUNTY AUDITOR
20 0 �- 20 20
P
County Auditor
property in question:
al PropeAy ❑ Mobile Home pC fr1.1-�
.o aoo(�:..�0.9 i
Dravr'cr i
��. .......
....
C1C(i ..........
20 20
Date
We certify under lhe penalty of peryury that the above and foregoing informalion is true and corred and ihat the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person
�