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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
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P�escribed by Department of Local Govemment Finance
INSTRUCTIONS:
Coun Township Year
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JUL �UF�`D�,t�rlc
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 0l the year fhe deduction is to be effective: 1//�
2J Mo6ile Homes assessed under IC 6-1.1-7: Befween January 15 and March 2 olt/ie yea `(he deductiomis�to be eNective.
See reverse side tor additional instnictions and qualifrcations. �CIBSON C�L'�i Y AUDi7C: � i
A plica t(owner or contract 6oyer- see
Record number O 3,�/��
!, Page number
V - OU - CO
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applipnt th� sole legal or equitable
March 1, curtent year March 1, current year owneR t�Yes ❑ No
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If no, whal is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than lhat of applicant, indicate below: Is lhe property in question:
Il� Real Property ❑ Mobile Home (IC E1.1-�
�ime of moRgagee or contract seller o
Address of moAgagee or contrad seller (number and street, city, state, ZIP
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Name of assignee or other owner or holder of mortgage �
Address of assignee (number and street, city, state, ZIP code) • Dta �
wer �,0. �.3 �
Does applicant own property in any other If yes, what counry? What Ta; �� C •••�°15+ �
county in Indiana? ard l�p '� No
COUNTY AUDITOR
Deduction approved in the amount of:
zo �_ zo Q,� zo � � 20 � zo � zo 09 zo
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Signalure County Auditor Dale
�� We ceAify under the penalty of perjury thal the above and foregoing infortnation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners /ull name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Ful r ent addres f applicant Address of authorized person