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i a�j STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'i' �. FOR DEDUCTION FROM ASSESSED VALUATION
`•. � «. -J Slate Farm 63709 (R6 / 5-06) . . . - , •
� Presaibed by Deperiment ot Local Gwemmertl Finance
INSTRUCTfONS:
To be filed in person o� 6y mail with the County Auditor o/ the county where the p�operty is located. fl � T 1 0 Z���
Filing Dates: 1) Real Property: Dunng the 12 months before June 11 of the year the deduction is to be eflectiS�.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the d�uc� is qbe eflective.
e�'/ ��6.p
See reverse side /or additional instnictions and qual�cations. � ("/
GIBSON COUNTY AUDITOR
Applicant (owner or confract
Taxing
Assessc�va}ue of
March 1, �urent yr
16 no, what is his
property as
see restrictions on reverse side)
4_� o n.� -�4 VA �. � �
Key n mber / legal description
exact share of interest?
name on record is diiferent than that of
of mortgagee or contrad seller
Si.aG+rT"
March 1, current year
below:
� �� � a � Page number
' lY� 1 �5 d
unpaid as of Is the applicant the sole legal or
ownef? �9es ❑ No
If owned with someone other than spouse, indicate with whom.
.
the
❑ Mobite Home pC 61.
dres of mortgagee or conUact seller (number and st2et, city,, state, ZIP i-- �`
Dra�ver i1'0...°�� .
Name of assignee or other owner or holder of mortgage � 10 ��
Card i\'p, ,. �
..........
Address of assignee (n'umber and street, city; state, ZIP code) ����"
�'• � 75,�C0
Does applicaM own propeAy in any other If yes, what county? Whal Taxing District? nd, ,,.._ _ i requested on
county in Indiana? I property for current yeaf? � Yes ❑ No
approved in the amounl of:
20�_
Signature
20 �
COUNTY AUDITOR
20 20 20
County Auditor
20
Date
20
�� We certify under the penalty of peryury lhat the above and foregoing information is true and corred and that the appiicants was / were
�esident of Indiana and owner of the aforemenlioned property on March 1, 20
Signature (owners /ull name) Person authorized by duly execuled Power of Attomey
1 n �_ . . . .�i /� D_ . D.. . �% . � or by IC 6-1.1-12-.07
' IAddress of authorized person