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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
O FOR DEDUCTION FROM ASSESSED VALUATION
f'-1 Preto Form b (r1/6-09)
Prescribed by Department of Local cowemmem Finance FILE
INSTRUCTIONS: om��
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. J U P G O [11 y�tp
4
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought ❑ County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months /1
before March 31 of each year the deduction is sought -/// ❑_�'f O'hTe er
See reverse side for additional instructions and qualifications. A D t1�, \(G�/IBSON COUNTY AI If]ITOR
Apprirant(ow2er wcontraa a restrictions on reverse ) t \ p-�-t V. Y ` .ftp
Taxing (, ( Ll t Keyitumber/I Ides.74L. �Q o �I Record u tier Pagenumm ,,
a mt, a Co- c.23-35- - 3 c o - co ( .-1 R 9 - 6 a-1 I P F
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as Is the applicant the sole
Marti 1,avrent year March 1,current year date of application legal or equitable owner?
5 et )\b 6 ❑ Yes ❑ No
H no,what is his/her exact share of interest? Y' 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 Horne(1C 6-1.1-7)
Name of mortgagee or contract seller
'E. "CC. 0 _ _
Address of mortgagee or contract seller(number—' --
Name of assignee or other owner or holder of mo
Drawer NO • •
Address of assignee(number and street,ay,star 3!�����,
Card NO. ........... ... ......
� �....
Does applicant own property in any other r7-l/� Has this deduction been requested an property - I
munty in Indiana? ❑ Yes t�('tvt I for anent year? {4`—JC.U,Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount at
20 20 20_ 20 20 20 20_ .
Signature of County Auditor • County Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
1 nowner I rcoon/tr�at buyer of the aforementioned property on date application is filed.
` \1 l VIJtY) ` ? �-+�/ ` I Date(rrorRh.day,year)
1 resident address of applicant(number.and stree/e ooy,state,and ZIP code)
Person authorized by au�r duty W Sickle or bIC IC 4.1-12-0.7 Date(month,day year)
Address of authorized person (number and street city,start end ZIP code)