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:�'a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count I Township I Year
f/ ? FOR DEDUCTION FROM ASSESSED VALUATION y I `}
1-r Pres Form by Department of L) It/ED (%)
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Prescribed by Department d Local Government Finance
I.
STRUCTIONS: File Mark
To be bled in person or by mail with the County Auditor of the county where the property is located. AUG 5 2013
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2) Mobile/Manufactured Homes not assessed as Real Property:Must tile during the twelve(12)months byre Marc l 31 o each ar
the deduction is sought.
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR
App (owner or contract buyer-see estdctions on reverse Vie)
0\CSCES 2S L— an a Dr NC(0\
Tax is.nn Key number I legal description Re d num r Pa a num
Incz,A)� 2(�-la - Of-/DO-DO3.'9o3 -o)-c) I �- I S
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
March 1,current year March current year date of application legal or q'y Ne owner?
ASa (ou5 - 3O 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 applicant,indicate below Is the property in question Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name pf mortgagee or contract seller
1 ?RA) )) 1Y\OC-I L F \n( -
Addr ss of mortgagee or contract seller(numb ds7 et,city,slap,and P code)
IP �O CX,� IL, Ira- ‘v-� DO In d.>?p end&rz b-H- I-1413)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city state,and ZIP code)
Iles applicant own property in any other If yes,what county? - What Taxing District? Has Nis deduction been requested on property
my in Indiana? - fa current year?-
❑ Yes No ❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signet e a o{ Ipf County Date(month,day,year)
1 I We certify under the penalty of perjury that the above and foregoing informati•• 's true and correct and that the applicant is a resident of Indiana and
owner/cgntract buyer of the aforementioned = ••- on date application is 'ed
Sign re(owners NO a e �//' Date(mopth).Ida(y,ye/ar/L,
•
Full resident address of applicant(number and street, Y state,and ZIP code)
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day.year)
Address of authorized person (number and street.city.state,and ZIP code)