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STATEMENT OF MORTGAGE OR CONTRACTiNDEBTEDNESS
F FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
. w � SUte Fwm 43709 (RS / 6-03) �
� PresaiDed by Department of Local Govemment Finance
wsrRUCrroNS: AUG 3 OFP�I��
To be filed in person or 6y mail with the County Auditor of the county where [he property is located. �
Filing Da(es: 1) Real Property: During the 72 months be%re May 11 0/ the year the deduction is to 6e ve. �
2) Mobile Homes assessed under fC 6-1.1-7: Between January 15 and March 2 of the yea �d�t� to be eHective.
See 2verse side /or additional instructions and qualifications. GIBSON COUNTY AUDITOR
Applicant (ow e or contract b� - seg�estnctions on reverse side) �
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Taxing Distrid Key number / legal description cord number
5
��� Q� —O/o2 Pagenumber JC�B�
Assessed value of real property as of Mortgage / ContraU indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrcent year March 1, current year owner? �''�'es ❑ No .
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on recotd is different than that of applicant, indicate below: Is the property in question:
- L�al Property � Mobile Home (IC 61.1-�
�3me oi mortgagee or contract seller �/
�
Address of mortgagee or contraa seller (number and stieet, city, state, ZIP
Name o( assignee or other owner or hoider of morigage
Address of assignee (numberand street, ciry, s(ate, ZIP code) -
Dces applicant own property in any other If yes, what county? What Taxing District? Has this deduclion been requested on
county in Indiana? propeAy for current year? 0 Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �� 20 20 Q'L 20 20 �� 20 20
P P p
Signature County Auditor Date
We certify under the penalty oi perjury that the above and foregoing information is true and corred and thal the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Sig re{owners fu ame) Person authorized by duty executed Power of Attomey
�� or by IC 6-1.1-12-.07
F II re ident address t applicant Address of authorized person
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