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��' "�� 4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' = FOR DEDUCTION FROM ASSESSED VALUATION
J Stata Fwm a37W (R6 / 5-06)
� Presvibed by Departmenl of Laal Govemment Finance
Coun Township Year
� � � �
APR 3 ��
INSTRUCTIONS: Ff�' Mark
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dafes: 1) Real Properry: Dunng the 12 months belore June Il of the year the deduction is to be �s"ctiKB ,l��
2) Mobile Homes assessed unde� IC 6-iJJ: Between January 15 and March 2 0/ fhe year the deductiQn is to be eflective.
GIBSON COUNTY AU01idR
See reverse side for additional instrucUons and qualilications.
�p��.
Assessed value of real
March 1, current year
no,
- see
Key numbe� / legal description � Record number
l Cp' �d�' ��pZ�� �Q�-00�•�� ryy�.yiuniuei /1 /
U// V
as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or e
March 1, cunent year p owner? � Yes � No
C�O �q�9�
�e oi interest? If owned with someone other than spouse, indica[e with whom.
IT name on record is different than that of applicant, indicate below:
�e of mortgagee or wntract seller
C�i
Address oi moRgagee or conVact seller (number and street, cily, state,
or ofher owner or
and street, city, state. ZIP code)
Does applicant own property in any other I If yes, what county?
wunty in Indiana?
20� I 20
Signature
s the property in quE
0 Raa� o-'�- �
ac�'T.........
v�.�,���� �o.........
a�7 5.......
c.�,�a �o� ���;4�4�. °9�
Tauing District?
COUNTY AUDITOR
amount of:
20 �_ 20 20
� P
County Auditor
,'e Home (IC 61.1-7)
�
Has this deduction been requested an
property for wrrent year? ❑ Yes❑ No
20
20
We certify under the penalty of perjury that the above and foregoing iniortnation is We and cortect and that the applicants was / were
�sident oi Indiana and owner of the aforementioned property on March 1, 20 .
nature (owners full name) .D Person authorized by duly executed Power of Attomey
�.O.n.nl ,.,,,. f1Ann„l, orbylC6-1.1-12-.07
�a90 yI.
of
Address ofauthorized person