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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
'z FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�. ��� ! State Fwm a37p9 (RS / 4-03)
� PiescnGeA Ey Depertment of Local Gdvemment Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail wiih the CountyAuditor ol fhe county where the property is Iocated�AY 3 1 2005
Filing Dates: 1) Real Property: During the 72 months belore May 71 of tAe year the deduction is to e effect�ve.
2) Mobile Homes assessed under IC 6-1.1-7• Between January 15 and March 2 of the year the deduction is to be effective.
See reverse side /or addilional instnictions and qualifications. aaaU���... '�
GIBSO��U�TY AUDITOR
(owner
Taxing Distrid
�1T �`C.�l.�[./I�
Assessed value of real property as of
March 1, wrrent year
side)
Key number / legal description Record number
O - a (, � ie
O "�ho �((S„O�\ Pagenumber
lJ v
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
If no, what is his / her exact share of interest? �
If name on record is different than that of applicant, indicate below:
of mortgagee or contract seller
Address of mortgagee or contred seller (number and street, city,
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand stieet, city, state, ZIP code)
Does applicant own property in any other If yes, what county?
county in Indi���2 __ _ _
/�' Q- �+ � .
l.µa0
Deduction apE
20
If owned with someone other than spouse, indicate with whom.
s ihe property in questian:
❑ Real Property ❑ Mobile Home (ICft7.1-�
What Taxing District? Has this deduction been requested on
property for current year?� Yes❑ No
Drawer NO ..................• Y AUDITOR
aZo'ao.oe ���✓
CardNO . ................
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P I t� I P
Signature
County Auditor
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We certify under the penalry of perjury that the above and foregoing information is true and correct and ihat the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20 -
Person authorized b�
or by IC 6-1.1-12-.07
executed Power of Atlomey
Full resident address of applicant �Address of authorized person