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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
�+� �«• ! State Fwm a37p9 (R5 / 4-03) � ' . '
� Pfespip¢d py Depanment of Local Govemmenl Finance
INSTRUCTIONS: MAR 4 �B�a�`
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1 f Real Property: Dunng the 12 months 6e%re May 11 of (he year the deduciion is to�-� R,,ective.
2) Mobile Homes assessed unde� IC 6-1.1-7: Between January 15 and March 2 of the y�`a4'lbe�d,�d�n is to be effective.
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See reverse side for additional instn�ctions and qualifications. GIBSON COUN7V qUDITOR
Appticant (owner o ntrac( buyer- see ricti s on reverse side) �
Taxing Dislrid Key number / legal descriptio Record number Q
�-}— � /%� 1 � � QQ � Q`).�+j�-\ Page number � �/ �
li a� l Cbr �.x.� ��
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is lhe applicant the sote legal or equitable
March 1, current year March 1, current year owneR ❑ Yes ❑ No �
ii no, whal is his / her exacl share of interesl? If owned with someone other than spouse, indicate with whom.
If name on record is different than ihat of applicant, indicate below: Is the property in queslion:
❑ Real Property ❑ Mobile Home QC 61.1-�
�e of mortgagee or contract selier
Address of mortgagee or contract seller (number and streef, city, st , ZIP
Name oi assignee or other owner or holder of mortgage
Address of assignee (num6er and streef, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? propeRy for wrrent yeaf? Q Yes ❑ No
COUNTY AUDITOR
Dedudion approved in the amounl of:
20 � 20 �_ 20 �_ 20 _� 20 20 20
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SignaWre County Audilor Date
We ity under ihe penalty of perjury lhat the above and foregoing information is true and corred and that the applicants was / were
:si nt of Indiana and owner of the aforementioned property on March 1, 20
i a r�ivnefs ful na Person authorized by duty executed Power of Attorney
� ; or by IC 6-t.t-12-.07
Fu re t addre of pplicannt• _�— A dr�ss of ut ' ed person
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