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i i � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
°i' s FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� --,w. -J State Fwm 43709 (R6 / SO6) �
Presaibetl by Deperiment of Local Gwemment Finance 1
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INSTRUCTIONS: GLT 3 O p�La a�`
To be filed in person or by mail with the County Auditor ot the couniy where the p�operty is located. � �
Filing Dates: 1) Real Property: Dunng the 12 months before June Il o/ the yea� the deduction is to be elfective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the yearjthe ded'ucL�n is to be eNective.
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See reverse side for additional instructions and qual�cations. QIBSON COUNTY AUDI70R
Applicant (owner
Taxing Distrid
see
Key number / legal description Record numbe� �– ��/ �
a6 -r �. o �. y o, . uar. o�t=o,yf ��
Y � n _ � /0 - � Page number
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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, cunent year owneR C❑ Yes ❑ No
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If no, what is his / her exact share of interest? It owned with someone other ihan spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
�me of mortgagee or conVad seller /�
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Address of mortgagee or contred seller (number and street, aty, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other I If yes, what county?
county in Indiana?
20 � I 20
Signature _
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the amount o
�_ 20 � �
P �°
❑ Mobile Hane (IC 61.1-�
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Taxing V�_.. 1 �
COUNTY AUDITOR
20
County Auditor
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20
20
�ested on
i YesO No
We certify under the penalty of peryury that the above and foregoing information is true and corred and that the applicants was / were
residenl of Indiana and owner of the aforementioned property on March 1, 20
(ow�ers (ull name) , �
�.r�tc, � _ �?� �
executed
or by IC 6-1.1-12-.07
of authorized person