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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
� FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Yez
�. / State Fwm 43709 (RS / 4-03)
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� PasaiDeE by Department ol Local Govemment Finance
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INSTRUCTIONS: 1'i ti. 1+ File Mark
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To 6e filed in person or by mail with the County Auditor of the county whe2 the property is located. 1 1 20�3
Filing Dates: 1) Real PropeRy: During the 12 months be7ore May 11 0l (he year the deduction is to be e/�esbve.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the year the deduction is to be eflective.
See reverse side for additional instructions and qualifications. �
.5.�-✓T�._
- GIBSGt< C�: . - -
or contract
Assessed value of rea( property as of
March 1, current year
If no, what is his / her exact share of
If name on record is different
of mortgagee or contract
m
Ke/ number / legal description I Record num�r a_ O/� L/
�.! /
�O � — O / �OO _ Page number
Mortgage / Contract indebiedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? �%es ❑ No
O
If owned with someone other than spouse, indicate with whom.
Address of mortgagee or contract seller (numha�-
of assignee or other owner or
Address
street,
Does applicant own property in any other I If ye
county in Indiana?
Deduction approved in the amount of:
20 Q�
P`rAl�o�
Signature _
ri �r' � s
We certify under the penalty of perjury that t
esident of Indiana and owner of the aforemi
below:
I resident address o�applicant 4T
R\ �o�L. a.�lA C��..�a.i.�.:,.Q�c . �i,.,,
V"(.�.
Is the property in
70 �� ��v
�.d .
n , ._./
Person authorized by duly executed
or by IC 6-1.1-12-.07
4ddress ofauthorized person
❑ Mobile Home (IC Gt.
been requested on
year? � Yes ❑ No
20
Attomey
was I were