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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION hr
f-:Jf t1 State Farm A37W(R71/6-W)
Prescribed by Department of local Government Finance
File Mark
INSTRUCTIONS: J U NFr1�n me�
fi be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located.
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought 9 County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)months n,
before March 31 of each year the deduction is sought - .//G_ n Recorder
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR
Appriant(owner orconb-act buyer- recs_t Action//Q�^-averse side)
'�'•'t�I rvrmberi legal description a Na-?, , Record number Page artier
Ta: /r: - / Key
�x L , a & - Pi- /8- 30Y-coo. S,t 6-oz6 010/ ti /o?--7
Assessed value of real property as of e/Contraa indebtedness unpaid as of Mortgage/Cantaa indebtedness unpaid as of Is the appfaant the sole
March 1,current year Marts i.current year date of aPPGCation legal n equitable awne?
( 20, oou ❑ Yes 0 No
If no,what is his/her exact share of interest? If owned with someone other than sparse,indicate with whom
If name on record is different than that of appbcant.indicate below: Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
Mobile Horne(1C 6-1.1-7)
Name of mortgagee or contract seller // 11 t
CA e-a/rj i- 2 .c 1 61-•. 24x►-4-e*
Address of mortgagee or contract senor(number and steel city,sate,and ZIP code) ________I
Name of assignee or other owner or holder of mortgage ,�11
Drawer NrO 2V /�/7I
Address o ' nee(number and street oty state,and ZIP code) J.,
— 33 w 3 y pr
7�
Does applicant own property in any other If yes,what county? What Taxing District? Card i,rO'
county in Indiana? ❑ Yes ❑ No ••• ."�••••• •••••
COUNTY AUDITOR
Deduction approved in the amount of
'
20 20 20 20 20 20 20
Signature ofJ - -12A Auditor. , /% 4 • County Date(month,day,year)
I/We rce/1`r6nfy un✓derr the penalty of perjury that the •bo d foregoing information is true and correct and that the applicant is a resident of Indiana and
owner l l w -r of the- .,.. entioned . .. . on date application is filed.
` ' Signet' a me Date(month,day,year)
SFull residepta. t( -• --t aly,state,and ZIP code)
C 6 D E Z..--o -- vs-7,- 5"1 .`.si --z �� 49C`/P
Person authorized by duly executed Power of Atomey or by IC 61.1-12-0.7 Date(month,day,year)
1 -- '''- lyiy
Address of out o-Med person (number and street city,state,and ZIP code) •