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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�+ J Sute Fwm 43709 (RS / 4-03)
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� Presaip¢C py Department of Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor ot the county whe2 the property is located. JQ y 2 U 200 t
Filin Dates: 1 Real Pro e Dunn the 12 montbs be%re Ma 11 of the '�
9 ) P RY 9 y year the deduction is to be eflective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the1 �deductio`�n is to 6e eRective.
See reverse side Ior additional instructions and quali�cations. ��
GIBSOk ;
Applicant (owner or contract buyer - see
Taxing
Assessed value o( real property as of
March 1, curtent year
Ii no, what is his / her exact share of inleresl?
name on record is different than thaf of
of mortgagee 9r,contrect seller
Address ot mortgagee or conlrad seller
2verse side)
Key number / legal description
t�i � — c�i U
MoAgage / Contrad ii
March 1, current year
indicate below:
Record number
Page number
unpaid as of Is lhe applicant the sole legal or equitable
owneR �s ❑ No
If owned with someone other than spouse, indicate with whom.
and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Is the
❑ Mobile Home QC 61.1-�
Address of assignee (numberand st�eet, city, state, ZIP code) ._.. . .
DrawerNO.......
Does applicant own property in any olher If yes, what county? What Ta> U J�/ T�� �sted on
counry in Indiana? Card NO . .....................
es � No
, COUNTY AUDITOR
Deduction approved in the amount of:
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Signature
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P P �
County Auditor
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Date
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We certify under the penalty of perjury that the above and foregoing information is true and corred and that ihe applicanls was / were
esidenl of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person