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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
's _� � J SHte Fam 43709 (RS I 6-03) � � , �
� PreSCnDed by Department of Local Govemment Finance �'
INSTRUCTIONS: � FEBFile �a�06
To be filed in person or 6y mail with the Counry Auditor of the county where the propeRy is located.
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 of the year the deduction is to be e/%cti�e�, �i�.
2) Mo6ile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 oI the year the dg"ddEf�/�!'�, �to ye e((gC'ive.
See reverse side Ior additional instructions and qualificatrons. G�gSON Cu�NTY AUDITOR
Applicanl (own or contract bu r- see re ' tio s on reverse side)
Taxing Disirid Key number / legal description Record number �
�I � � l'� Page number � `
� � S
Assessed value of real property s of Mortgage / Contract indebtedness unpaid as of Is ihe applicant the sole legal or equitable
March 1, wrrent year March 1, currenl year owne(? ❑ Yes ❑ No
[ VY�/
If no, what is his / her exact share of interest? If owned with someone olher than spouse, indicate with whom.
If name on record is different lhan lhat of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC E1.1-�
�me of mortgagee or contrad seller
Address of mortgagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of moAgage
Address of assignee (number and sfreet, city, state, ZIP code)
Dces applicant own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
counry in Indiana? property for current yea(? � Yes� No
COUNTY AUDITOR
Dedudion approved in the amount of:
20 " 20 _Q� 20 �q_ 20 20 20 . 20
� P
Signature County Auditor Date
�We certify under the penalty of perjury that the above and foregoing intormation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
n e(owners lull name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
F res' nt addr s of appli t Address of authorized person �
`I_ '-( 6'1 D