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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
= FOR DEDUCTION FROM ASSESSED VALUATION
• �w� ! State Fwrt; a37W (RS / 4-03) .
� Presai�ed by Departrtreni of Local Govemment Finance �
INSTRUCTIONS:
To 6e filed in person or by mail witA the County Auditor of tAe county where the property is located.
Filing Dates: 1) Real Pioperty: During the 12 months belore May 11 o/the year the deduction is to be e/��1,Ge. 4 2QQ6
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be effective.
See reverse side fo� additional instructions and quali(cations. '�j�a� �r�
� GIBSON COUNTY AUGITOR
Applicanl (owne�
Taxing Distrid .
s rev s ide)
_ T' lti L
Key number / legal description
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number
Page number
Assessed vatue of real property a�of Mortgage / Contract indebtedness unpaid as of Is the applicant lhe sole legal or equitable
March 1, current year March 1, current year owne(? ❑ Yes ❑ No
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Ii no, what is his / her exact share of interest? t owned with someone other than spouse, indicale with whom.
If name on record is different than that of applicant, indicate betow: Is the property in question:
of mortgagee or wntraU seiler
Address of mortgagee or contrad seller (number
Name of assignee or other owner or
oi mortgage
city, state, ZIP
Address of assignee (number and stieet, cify, state, ZIP code)
❑ Real Property p Mobile Home
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n �� t a-�
Does applicant own property in any other I If yes, what county? I What Taxing District? Has this dedudion been requested on
county in Indiana? property for current yeaf.� � Yes � No
Deduction approved in the amount of:
20
Dra�ver N�"
Signat \ �(��� � •
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COUNTY AUDITOR
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Auditor
Zo
zo
Date
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c _,.� ,ne penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
ient of Indiana and owner of the aforementioned property on March 1, 20
full
Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
�ess orap i�cant �-7 / /�,� Addressp, f authorized person
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