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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�'+ ! SUte Fam 43709 (RS / 4-03) . � � �
� PresuiDed by Department of Local Govemment Finance
INSTRUCTIONS: MAR O �il��k
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months belore May 11 0/ the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7: Befween January 15 and March 2 of the year�itr@J�uc6'oi�is to be effective.
See reverse side tor additional instructions and qualifications. GIBSON COUNTY AUDITOR
Applicant
Distrid
i 1
,�'.�
Assessed value of reai property as of
March 1, current year -
If no, what is his / her exad share of interest?
f� verse si )
%
Key number / legal de
Record
/� //� b� � �� '� Page number /��./.
(/ /7
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitab�e
March 1, wrrent year owneR � Yes ❑ No
�O ��
If owned with someone other than spouse, indicate with whom.
If name on record is different than ihat of applicant, indicate below:
�me of mortgagee or contrad seiler /�
v
Address of mortgagee or conlracl seller (number and street, city, state, ZIP
Name of assignee or other owner orholder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Doesappliwnt Drawer NO ...................
county in Indiar /1 /
Card NO. . v.�..�..1..��%
aPp�'---- -- --- ....
20 _�
Signature
20 _Q� I 20 �_ I 20
VYhat Taxing Distrid?
ITY AUDITOR
20
County Audifor
❑ Real Property ❑ Mobile Home (IC 61.1-�
Has this dedudion been requested on
property for current year?� Yes❑ No
20
Date
20
certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
(owne/s (ull name)
Person authorized by duty executed Power of
or by IC 6-1.1-12-.07
address of applicant � Address of authorized person
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