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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
'+ � 1 State Fortn 43709 (R6 / 596) � � i
� Presai6eA by Depannent of Lotal Govemment Finance �
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INSTRUCTIONS: ,I U �'��M�`� 007
To be (iled in person o� by mail wrth the County Audito� o/ the county where the p�operty is located.
Filing Dates: 1) Real PropeRy: Dunng the 12 months before �une � 1 0l the year the deduction is to be eflecfive.
2) Mo6i/e Homes assessed under lC 6-1J-7: Between January 15 and March 2 of the year the �d[sµ6�n �to-�-b� e8ective.
See �everse srde foradditional instruclions and qualifications. GIBSON COUh'TY AUDITOR
Applicant (owner or contracf buyer- see strictions on re erse si e)
a.
Taxing District Key number / gal description Record number ..
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% � Page number
ii.0'�\ a lo-!c7 -l8 -/0 / -GY7 /_ a � -o � .
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant he sole leg I or equitable
March 1, current year March 1, current year owner? s❑ No
O
If no, what is his / her exad share of interest? Ii owned with someone other lhan spouse, indicate with whom.
If name on record is difterent than that of applicant, indicate below: I the property in question:
Real Property ❑ Mobile Home pC Cr1.1-�
me of mortgagee or conVad seller
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Address of mortgagee or conirad selier (number and stieef, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6erand st2et, city, state, ZIP code) � n n , ^�
pC E�ORn5�1
Does appliqnt own property in any other If yes, what county? �. O1/`�'� h �n requested on
counry in Indiana? DI'��vCr 1�r�....RV�J., �, af�� Yes❑ No
Card i\'O. .. ...a„�,'79 .
couNrv � `� '15,o0U.°�°�
Deduction approved in the amount of:
20�L 20�_ 20 � 20 20 20 20
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Signature County Auditor Date
/ We certify under the penalty of perjury thal lhe above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 7, 20
Signature (owne/s /ull name) Person authorized by duly executed Power of Attomey
X .-�.N ,/__ i or by IC 6-1.1-12-.07
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F I resident address of applipnl Address of aulhorized person
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