Mortgage_Blume1�
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�.��P� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'r��; FOR DEDUCTION FROM ASSESSED VALUATION un Township Year
«. �' StateFortn43709 (R6/5-06) MQ 1 4 2��8
� Presaibetl by Department of Loral Gwemment Finance
INSTRUCTIONS: GIBSON COBi127MaR�c1DITOR
To be filed in person or by mail with the County Auditor of the county whe�e the propeRy is located.
Filing Dates: i) Real Property: Dunng fhe 12 months befo2 ,lune 17 0/ the yea� the deduction is fo be eflective.
2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 0/ the year the deduc6on is to be effective.
See reverse srde for additional instnictions and qualifications. ,
Appli ant (ownerorcontract uyer- s e 2stricfions on reverse ide) • �C.G;/�'�/�
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Taxing istrid ey number / legal description Record number
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`J / 3�_O a n Page number ��� p
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Assessed value of real property as ot Mortgage / Contrad indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, wrrent year March 1, current year ownef? ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is dif(erent ihan that of appticant, indicate below:
Dra���er NOaZ U��'. y4%Y�H��csi.i-�
e of mortgagee or contrad seiier �� ,
- ^Cal'(� �'�. ..... .� ........
Address of mortgagee or contrad seller (number and street, city, state, ZIF �
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and stieet, city, sfate, ZIP code)
Does applipnt own propeAy in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for wnent yea� 0 Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �_ 20 � 20 20 20 20 20
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Signature County Auditor Date
We certify under lhe penalty of peryury that the above and foregoing information is true and correcl and that ihe applicants was / were
asident of Indiana and owner of the aforementioned property on March 1, 20
S' '� ature (owners (ull name Person authorized by duly executed Power of Attomey
�, � � or by IC 6-1.1-12-.07
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ull"resident address o applicant Address of authorized person
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