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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
:�M� J State Fwm a37W (RS / 4-03) -
� PrescriEed by Department of Local Govemment Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Audiror o( the county whe�e fhe property is located. A P R 1 j Z�Qj
Filing Dates: 1) Real Property: During the 12 months before May 11 0l the year the deduction is to 6e effective.
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 2 0! the year t, he deductA� js to be effective.
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See reverse side for additional instnictions and quali�cations. Q ��
GIBSON COUNTY AUDITOR
(owner or contract
Taxing Distrid
Asses3ed value of'rea
March t, current year
Key number / le[al description � Record number
�0�� Q -0� Page number 'l � /O
, �� �/
of MoAgage / Contrad indebledness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owne(? ❑ Yes ❑ No
If no, what is his / her exact share of interest?
If
If name on record is different than that of applicant, indicate below:
�ne of mortgagee or contreIX seller
3
Address of mortgagee or contract seller (number and sfreet, ci , sfate, ZIP
of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
with someone other than spouse, indicate with whom.
Does applicant own property in any other If yes, what county? What Taxing Distrid?
county in Indiana?
Drawer NO..�� :,a,Y�; O ;OUNTY AUDITOR
Deduclic
zo 0
SignaWre
Card NO . .....................
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County Auditor
�
s the property in question:
❑ Real Property ❑ Mobile Horne pC 61.1
Has lhis deduction been requested on
propeAy for current yea(�� Yes❑ No
20
Date
zo
certify under the penalty of perjury lhat the above and foregoing information is true and correcl and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
full
address ot
r � 60�2
i
Person authorized by duty executed Power of Attomey
or by IC 6-t.t-12-.07
Address of aulhorized person