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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSEO VALUATION
State Fwm 63709 (RS / 4-03)
Pmscribed by Departmem of Local Govemment Finance
Coun Township Year
INSTRUCTIONS: FE��e�� 2005
To be �led in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be ef(ective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0! the year the d�tion ��eHective.
See reverse side /or additional instructions and qualifications. �Cl�
GIBSON COUNTY AUDITOR
Appiicant (owner or con cf b yer- see restricti ns on re erse side)
Taxin � trid Key num er / legal descripti ecord number �
, _n fR / Page number !�
"Z.J v ( d
Assessed va ue of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sote le al or equitable
March 1, curcent year March 1, current year ownef? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned wifh someone other than spouse, indicate with whom.
If name on record is diHerent than lhat of applicant, indicate below: Is the property in question:
❑ R PropeAy p Mobile Home (IC Cr1.1-�
me of mortgagee or contract seiler �
Address of mortgagee or contrad seller (number and s t. crty, s te, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and sfreet, 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? 0 Yes❑ No
COUNTY AUDITOR
Deduction approved in lhe amount of:
20 �J� 20 D'% 20 �� 20 O� 20 20 20
P �°
Signalure County Auditor Date
� We certify under the penalty of perjury that the above and foregoing information is true and correcl and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners /ull na Person authorized by duty executed Power of Attomey
• or by IC 6-1.1-12-.07
II resident addres applica Address of authorized person