HomeMy WebLinkAboutMortgage_Hasselbrink� STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�+ �M� i State Fwm 43709 (RS / 4-03) ' � .
� PtescnDed Dy Department oF Local Govemment Finance
To beR�UC�TIOP rson or 6y mail with the County Auditor of the county whe2 the property is loc� g 1L/ �j �
Filing Dates: 1J Real Property: During the 12 months 6efore May 11 of the year the deduction is to be ef(ective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the y�a�e�le�u�is to be effective.
See reverse side for additional instructions and qualifications.
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Applicanl (owner orcon ct yer- see restrictions o re erse side) • GIBSON COUNTY AUDITOR
Taxing Distrid Key number / legal description Record number ��
/lO � �a o�I / age number �
(J Y'
Assessed value of real property as of Mortgage / Contrect indebledness unpaid as of Is lhe applicant the sole legal or equitable
March 1, current year March 1, current year oaa ownef? ❑ Yes ❑ No
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If no, what is his / her exact share of interesl? Ii owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC E1.1-�
��e of mortgagee or contract seller
Address of mortgagee or contract seller (number and st et, city, sfate, 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? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current year?� Yes� No
COUNTY AUDITOR
Deduction approved in fhe amount of:
20 �_ 20 �� 20 � 20 0 20 20 20
Y �
Signature County Auditor Date
�We certify under the penalty of perjury that the above and foregoing information is true and corred and thal the applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
i ture (ownels /ull name) Person authorized by duiy executed Power of Attomey
� or by IC 6-1.1-12-.07
F I resident add ess of applicant ` Address of authorized person
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