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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
StateFam43709 (R6l5-O6)
Presaibed by Department of Local Garemment Finance
Coun Township Year
INSTRUCTIONS: � �il�rk� �
To be filed in person or 6y mail wdh the County Audito� of the county whe�e the property is located.
Filing Dates: 1) Real Property: During the 12 months belore June Il of fhe year the deduction is to be effe e.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the ded A�q� i§ f 8be effecfrve.
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See reverse side for addrtional instruc6ons and qualifica6ons.
Applicant (own o con6acf buye� - see restrictions on re rse ' e)
i GIBSON COUNTY AUDITOR
Taxing DisVict Key number / legal description Record number �/�
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Assessed value of real property as of MoRgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? � Yes � No
I( no, what is his / her exact share of interest? If owned with someone oiher than spouse, indica[e wiih whom.
If name on record is difterent than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home QC fr1.1-7)
�e of mortgagee or contract seiler ,
Address of moRgagee or contract seller (number and street, city, st ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numbe�and street, city, sr � �� ���SrE2� �Il'1 (�� ��"'
Does applicant ovm property in any other IT yes, y� C , Has this deduction been requested on
county in Indiana? � property for current year? Q YesO No
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Deduction approved in the amount oi:
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Signature County Auditor Date
I I We certify under the penalty of perjury that the above and foregoing infortnation is We and conect and that the applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
�,yna ure (owne/s tull name) Person authorized by duly executed Power of Attomey
or by IC 6-t.t-12-.07
ul resident address of applicant Address of authorized person
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