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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
t+ J State Fwrt: d3709 (R5 / 4�3)
� PfesaiEeA 6y Departmeni ot Local Govemment Finance �y� �
INSTRUCTIONS: Fi�e Mark
To be �led in person or by mail with the County Auditor of the county where the property is located. � U� 1 2 2QQ5
Filrng Dates: 1) Real PiopeRy: During the 12 months before May 11 of the year the deduction is to 6e eflective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/the year,�i,a� duf,tio is to effective.
See reverse side /or additional instructions and qualifrcatrons. ��� �
GIBSON COUNTyAk1BfT9q� I�'S
Applicant
bos.-oo 3� a age number
Assessed'value oi rea�roperty as of � Mortgage / Contract indebtedness unpaid as of Is the applicant the soie legat or equitable
March i, current year March 1, current year owne(? ❑ Yes ❑ No
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different ihan that ot applicant, indicate below: Is the property in question:
� —_— _ ❑ Real Prop�.�rty ❑ Mobile Home pC 61.1-�
mortgagee or contract seller
Address of mortgagee or wntiad 5elier (num er and street, c' , state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, stafe, ZIP code)
Does appiicant own propeRy in any other If yes, what county? I What Taxing Dislrict? Has this dedudion been requested on
county in Indiana? � prooeriv for wrrent year?� Yes� No
�.-�97%
Drawer NO••a•
Deductlon approved in the amount
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Signature
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Card NO . .....................
County Auditor
Date
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We certify under the penalty of perjury that the above and toregoing information is true and corred and lhat the applicants was / were
'esid�nt of Indiana and owner of the aforementioned property on March 1, 20
(owners full
of
Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
Address of authorized person