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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
�+ �w J State Farm 43709 (RS / 4-03)
� P25cribed by Department of Local Govemment Finance
INSTRUCTIONS --- -- �— �--.,, MAY 0 l c�)(�,nna�
To 6e filed in person or by mail with the County Auditor of the county whe2 the property is loca
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction �wto be e ec
2) Mobile Homes assessed under lC 6-1.1-7: Between January 15 and March 2 �,�1', eHective.
See reverse side for additional inshuctions and qualificafions. GIBSGtJ COUNiY AUDITOR
Appiicant (own or contracf buyer- see�estn'c ' s reverse si e)
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Taxing Dislri Key number / legal description Record number
�1 �3
� •.�, : O � — Q �� r'� Page number �V`1S
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, currenl year owner? ❑ Yes ❑ No
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If no, what is his / her exact share of interesl? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in queslion:
❑ Real Property ❑ Mobile Home QC 61.1-n
�ame of mortgagee or contrad seller �
Address of mortgagee or contract seller (number and st2et, city, state, ZIP
Name of assignee or olher owner or holder of mortgage
Address of assignee (num6erand st2et, city, state, Z1P code)
Does appliwnt own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amouni of:
20 _Q�" 20 20 20 �� 20 20 20
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Signature County Auditor Date
��! We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that ihe applicants was / were
resident of Indiana and owner of the aforementioned property on March 7, 20
i
Signature wners Iull name) Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Full re n dres ot applicant Address of authorized person