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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
'' '}J FOR DEDUCTION FROM ASSESSED VALUATION
'- State ibed 43709 Department 5) F I L
�--' Prescrbed by Department of Local Government Finance gBp J de�'1;
INSTRUCTIONS: •
To be filed in person or by mail. Formkled with:
Filing Dates 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought OCT 2 3 ?,B-1/
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is LJ County Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the ty • Rty Recorder
where the property is located dining the twelve(12)months before March 31 of each year the deduction
See reverse side for additional instructions and qualifications. G I B SO N COUNTY AUDITOR
App�i�ant(buyer- restrictions on reverse side)
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Taxing District Key number I legal.......-ii.....j Record number Page number
2..6 .4L1 arc - /9- /8- Aoo - ooI. 37 9- o d- 4 co l7 Yys's
Assessed value of real property as of Mortgage I Contact indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,arrant year assessment date,airiest year date of application legal or equitable owner?
OZ 20j 750 ❑ yes ❑ No
If nno,what is his 1 her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is efferent than that of applicant indicate below 1 Is the property in question:Annually Assessed
❑ Real Property ❑ AnnuallyAssessed
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— — -- -Mobile Home(IC 6-1.1-7)
Name of mortgagee or«{nape seller / G.L _
Address of mortgagee'or contract seller(number and sheet t . ,state,and ZIP code C
Drawer NO 26 19-
Name of assignee or other owner or holder of mortgage
Address of assignee(number end street dry,state,wand ZIP code) y 7 Ca rd NO. 14 M5.S ,If
a�applicant own in any If yes,wtt county? What Taxing District? Has�� been requested If yes,state amount a aeauman
in Indiana? ❑Yes ❑No current year? ❑Yes. ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity fine of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amomt of
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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
owner l contract• er of the . • -• -n'. ed pros,- on date application is filed.
Signature(avmw's:gr . .e)
Data(month,day,year)
VW` /Fu11 resident a. - of,.• /�y city,state.and P code)
4 ! r at lJtL Y7GY8
Persona i odzed by duly executed •/ - of Attorney or by IC 6-1.1-12-0.7 r Data(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)
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The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.