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� STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
S w� / State Form 63709 (RS / 4-03)
� PresaiDetl �y Deparimem of �ofal Govemment Finance
To 6eRfiled�'n�person or by mail with the County Auditor of the county where the property is located. � I �le M� �
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 2 of the year the d�(Dr�tion i� t����gffective.
See 2verse side lor additional instructions and quali(cation
%1 � �� O �l6�i N /�°�.
(owner or contract
Tauing
Assessed value of r�al property
March 1, current year
If no, what is his
exact share of interesl?
If name on record is different than that
of mortgagee or contrad
of mortgagee or
Key number /
GIBSON
Record number
DO� OOSo9�� Page number �O l�
O\
MoAgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
(i/ ��
If owned with someone other than spouse, indicate with whom.
indicate below:
(number and sfreet� city, state, ZIP
assignee or other owner or holder of mortgage
Address of assignee (num6erand s6eet, ci
Does applicant own propeAy in any olher
counry in Indiana?
Dedudion approved in the amount of:
20 � ifl 20 �
Signature
—�-- --.,..,._ -
Drawer NO...� ,
Card i� . ...°�°Z� ......
�'',, �o�.�e. �t.c.
20 � 20 d�
/ /
County Auditor
20
❑ Real PropeAy ❑ Mobile Home QC 61.1-�
Has this deduction been requested on
property for current year?� Yes❑ No
20
20
certify under the penalty of perjury that the above and foregoing information is true and corred and ihat the applicants was / were
!ent of Indiana and owner of the aforementioned property on March 1, 20
Signature
resident address of
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person