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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�. / State Fortn 63709 (RS / 4-03) ! �' '-� �
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PrescribeE by Departmem of laal Govemment Finance � ��7 ��
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INSTRUCTIONS: NOV ����(�5
To be filed in person or by mail with the County Audifor o/ the county where the property is located.
Filing Dafes: 1J Real Property: Dunng the 12 months be/ore May 11 of the year the deduction is to be eBecG~ve?
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the dedvcti�i�6e eHective.
GIBSON COUN7Y Auoitqn
See �everse side for additional instructions and qualifications.
cf buyer - see
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Assessed value of real property as of
March 1, wrrent year
If no, what is
exacl share of interesl?
on
n
Key number / legal description I Record number �, �
/n/�_ ���9 j—�i) Pagenumber ���
lY /
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
/ � �fl /1/Yl _ , �
name on record is different than that of applicant,
of mortgagee or contrad seller
Address of mortgagee or cont�act selier (number and
Name of assignee or other owner or holder of mortgage
of assignee (num6er and street, city, state, ZIP
Ii owned wilh sameone other than ��� ��m.
- ,,/V,S : �a-
beiow: ra.` er �1� �V
D , (IC61.
city, state, ZIP
Cara ��
Does applipnt own property in any other I I{ yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for curtent yeaR � Yes❑ No
COUNTY AUDITOR
)edudion approved in fhe amount of:
20 20 �� 20 � 20
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Signature
County Auddor
20
20
Date
20
We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
ature (owne/s full name)
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resident address of applicai
R2 i C3�,� 5� 9- N
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Address ofauthorized person