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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
-c: FOR DEDUCTION FROM ASSESSED VALUATION '(
_ t State Focal 43709(R11/609) �''� g ��''��
,/y Prescribed by Department of Local Government Finance A J I '
,STRUC7IONS: 11i
no be filed in person or by mail with the County Auditor or County Recorder of the county where the property is boated. A., N�with:
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. A G ] Nay Auditor
2) Mobile/Manufactured Homes not ae-c-ssed as Real Property Must file during the twelve(12)months
before March 31 of each year the deduction is sought ❑ County Recorder
See reverse side for additional instructions and qualifications. firr%r7171�r
Ap nt(ownerocontrad buyer-see on reverse side) GIBSON COUNTY AUDITOR
Ta strict Key number/egad description n Record number Page number
wzr ° a4 - !a _o_3 -- yoo - coo . cc 16-° A7 /3 3co30
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appfrant the sole
March 1,coed year Mardi 1,amen year date of application legal or equitable owner?
/ '7y "2 S.0 0 ❑ Yes ❑ No
If no,what is his/her exact share of interest? - If owned with someone other than spouse,indicate with whom
If name on record is different than that of appricant.indicate below. Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
Motile Hone(IC 6-1.1-7)
Name of mortgagee or contract seller -
Address of mortgagee or contract seller(number and street city.state,and ZIP code) Drawer N O
Name of assignee or other owner or holder of mortgage �)��
Card NO. 5 0
Address assignee(number and street city,state,and ZIP code)
1- u L 3 _ 3• a - /0 7 . 04-or A—c
Does applicant own property in any other If yes,what county? • What Taxing District? _ I
county in Indiana? ❑ Ves ❑ NO I for current year? ❑ Yes ❑ No
® COUNTY AUDITOR
Deduction approved in the amount of
20 20 20_ 20 20 20 20
Signature County(r� County Date(month,day,year)
I/We certify under the pens ty of perjury ury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
(month,re(owner's
name) - Date(no ,day,year)
ufl resident address of applicant(number and mgt city,stag,and ZIP code
6Z96 [- /Oa /V he/ le,cr ti -NW 9>A ) D
Person authorized by duty executed Power of Attorney or by IC 61.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street sty,state.end ZIP code)