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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
b� J Stare Fwm 43709 (RS / 4-03)
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Pre5rn0eE Dy Department of Local Govemment Finance
INSTRUCTIONS: Fiie Mark
To be �led in person or 6y mail with the County Auditor o/ the county whe2 the propeRy is located. Q� � 1$ 2��5
Filing Dates: i) Real Property: During the 12 months before May 11 0/ the year the deduction is to be elfective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 2 0/ the year-!he deduction is to be eHective.
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See reverse side for additional instructions and qualifications.
GIBSON COUNTY AUDITOF
Applicant
District
��okQT,,�-
Assessed value ofrealproperty as
March 1, current year
see
no, what is his / her exact share of interest?
If name on record is different than thai
number / Iegal
bo�-ot
Mortgage ! Contrad ir
March 1, cu�nt year
indicate below:
If
Recordnumber O�
� Page number �O/ Z
6
unpaid as of Is the applicant the sole legal or
owne(? ❑ Yes ❑ No
wilh someone other than spouse, indicate with whom.
is the property in questian:
� Real Property O Mobile Hane (IC 61.1-
r3me of moAgagee or contrad selier n � I ��'
l ' r'1 .l•�i
��/ II
Address of mo�tgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county?
county in Indiana? .
Deduction approved in the amount of:
20 _Q�
Signature
20 ��
P
couNrv
20 �� 20 _
P
County Auditor
� Drawer ( (�i °n requesled on
��•..., e+- �b� af?QYes�No
........... p�°
Card NO .....................
20
+3�7
20
We certity under the penalry of perjury that the above and foregoing information is true and corred and that lhe applicanls was / were
resident of indiana and owner of the aforementioned property on March t, 20
0
name)
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Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
person