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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATiON
Slate Fwm 63709 (RS / 4-03)
PreSCnbeO Dy Department ot Local Govemment Finance
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INSTRUCTIONS: � �i1°�
To be filed in person or by mail with the County Auditor of the county where the property is located. A� � 2 L L�
Filing Dates: 1) Real Property: Dunng the 12 months be%re May 11 oI fhe year the deduction is to be eflective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year-t � edu�p�s_to be effective.
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See reverse side for additional insfructions and qualifications. U
GIBSON COUNTY AUDITOR
Applicant (ow orcontracf buyer- see restrictions on reverse side)
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Taxing Distrid Key number / legal description Record number
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�„-�=j), ^^ �_�3�_ � Pagenumber 5 � aa-
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is lhe applicant,Ehe sole legal or equitable
March 1, wrrent year March 1, current year ownef? ��� s❑ No
5d00
If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on iecord is diHerent lhan that of applicanl, indicate below: Is the property in question:
❑ perty ❑ Mobile Hwrie pC 61.1-�
�me of mortgagee or contract seller
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Address of mortgagee or contracl seller (number and street, city, state, ZIP
Name oi assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code) _�
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Does applicant own property in any other If yes, what counry? What Tai � r� �. , ••;,�, �sted on
counry in Indiana? DTa�Ver � S�J� es❑ No
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Card NO. ........� .........
`�-�P 7� -// �• SO4�, COUNTY AUDITOR ���j Q�.�. 55 .°`°
Deduction approved in the amounf of:
20 20 O� 20 20 20 20 20
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ISignature County Auditor Date
�/ We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
Si ure (owners full name) Person authorized by duly execufed Power of Attomey
or by IC 6-1.1-12-.07
Full sident address of applican Address of authorized person