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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�• ! Siate Farm a3709 (RS I4-03)
� 'N�
PmscnDed by Departmeni ot local Govemment Finance
INSTRUC7IONS:
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: Dunng the 12 months before May 11 01 the year the deduction is to be eifedfve� 8�QQ�
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 0! the year the deduction �s to be e(fective.
See reverse side for additional instructions and qualifications. Ojla� ,�/��
G�BSON CUUNTY qUfH�no
IApplicant (ownerorcontract ¢py see restncfions on .. i ri , ..�
District
Assessed vatue of real property as of
March 1, wrtent year
If no, what is his / her exact share of interesl?
Key number / legal description �
�.�-o�{-a�-3oo-000, oi8-ot
0�� -600/8-��
Mortgage / Contract indebtedness unpaid as
March 1, current year
r�a ,. .,-,� 5�. � 7 �
name on record is difterent than that of applicanf,
of mortgagee or conlraIX seller
Address of mortgagee or contrad seller (number and
Name of assignee or other owner or
of mortgage
below:
Record number 0 �
Page number /� O �
f Is the applicant the sole legal or equitable
ownef? ❑ Yes ❑ No
If owned with someone other than spouse, indicate wilh whom.
city, state, ZIP
s lhe property in question:
� Real Property ❑ Mobile
61.1-�
Address of assignee (number and street, city, state, ZIP code)
Dces applicant own property in any other If yes, wh ��� M� � S'�� LL this deduction been requested on
,i
county in Indiana? erty for wrrent yeaf?0 Yes❑ No
t
�RK.dARA� S /1 Iq
Deduction approved in the amount of: � I" I r] ��
20 0�1
Q
Signature
2o r�x I 20 �`� I 2o I 20
P P
County Auditor
20
20
✓e certify under the penalty of perjury ihat the above and foregoing information is lrue and corred and that lhe applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
�tur (owners full name) Person authorized by duly executed Power of Attomey
'�G1if,�, h�.,.. _ 1_ �_ or by IC 6-1.1-12-.07
sident "a�idress of applicant � Address of authorized person
�°� j� l' // / ��'P ..7/� � o/Y�Q �✓7//_ /