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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
� FOR DEDUCTION FROM ASSESSED VALUATION ' Coun Township Year
�� / State Porm a37091R5 / 4-03) . � � , . .
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� PiescnDed by Department af Loral Govemment Finance �
'To beRUC TION rson or by mail with the County Auditor of the county where the property is located� ��F1��
Filing Dates: 1) Real Property: During !he 12 months before May 11 0/ the year fhe deduction is fo be eHective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year tf�(il�d�h`�n��be effective.
See reverse side for additional instnrctions and qualifications.
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Applicant (owner or contract buyer- see resfri ' ns on reverse side) � GIBSON COUN
/ C�-
Taxing Disirid Key number / legal description Rewrd number
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_ � � � ���� �p� Page number a B �
Ol (�(J
Assessed value of real property as o( Mortgage / Contract indebledness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year ownef? ❑ Yes � No
� S�JI� 1! 1
If no, whal is his / her exact share of inlerest? Ii owned with someone other than spouse, indicate with whom.
If name on record is diHerent than lhat of applicant, indicate below: Is the property in question:
❑ Real Property p Mobile Home (IC 61.1-�
�me of mortgagee or contrad seller
Address of mortgagee or contrad seller (number and stree city, state, ZIP
Name of assignee or other owner or hotder of mortgage
Address of assignee (num6er and streef, city, state, ZIP code)
Does applicant 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
DeducGon approved in the amount of: �
20 �f % 20 a�` 20 Q� 20 20 20 20
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Signature County Auditor Date
�l We certiry under the penalry of perjury that the above and foregoing information is trve and corred and that ihe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Si ature ( wne s/ull name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
ull re t address of applicant Address of aulhorized person -