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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township I Year
so"--,v:a FOR DEDUCTION FROM ASSESSED VALUATION
State 43709(R
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Prescribed by Department of local Government Finance I E T
INSTRUCTIONS:
b be filed in person or by mail with the County Auditor or County Recorder of the county where the ro Form mad with:
ty fY P Pe fY is located. ��'Q C �n
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought t UGC &rdltltihW ditor
2)Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months
before March 31 of each year the deduction is sought - ❑ County Recorder
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See reverse side for additional instructions and qualifications. 1 ' VI r71f►I r
G (owner or contract buyer-r e restrcxns a side) GIBSON COUNTY AUDITOR
Taxi'DstrirS Key number/legal description -Record a number
4, -/5'-D? - `foo -oo/ �ti8-ooh �3 /9(//
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current year data of application legal or equitable owner?
!18 00 /D ❑ Yes 0 N
If no,what's his/her enact share of interest? ll owned with someone odor than spouse,Indicate with whom
If name on record is different than that of applicant Indicate below Is the property in quesfvn_Annually Assessed
❑Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
.W"-.
Address of mortgagee or contract seller(number and street,city,sata,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address assignee(number and street city:"a'-,and ZIP code)
Does applicant own property in any other If yes,what county? I Mat Taxing District? Has this deduction been requested on property .
county in Indiana? ❑ Yes ❑ No y/J� for current year? )❑ Yes �❑)No -
COUNTY AUDITOR 1 DPP, K&PFr� `��
Deduction approved in the amount of
uaTreiz D
20 20 20 20 20.
Signature County Auditor / • County - /9-3 1941
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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
owner/contracctt buyer of the aforementioned property on date application is filed.
k//Signature( k/ Data(month,day,year)
/(
Fun!rresident address of ap umber and steer,.dryy,state,and ZIP code) ��//_./.,
\ C.�S S. (22 5 r of Attorney or by IC Gv?a-0�j Yc} Z r '(00 Date(miorrdt.daY.year)
Person authorized by Address of authorized person (number and street dry,state,and ZIP code),l// .