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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form a3709 (RS / 4-03) .
Presaibed by Department of Lorrdl Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the CountyAUditor of the county where the property is located. � z g 20�4
Filing Dates: 1J Real Property: Dunng the 72 months be%re May 11 0/ the year the deduction is to be eff�c�ve.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the gr the ded ctr " s to 6e effe tive.
See reverse side (or additional instruc[ions and qualiTcations.
GIBSON COU TY AUDITOR
Applicant (owner co tracf 6uyer- see
Taxing Distrid
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Assessed value ofrealproperty as of
March 1, current year
If no, what is his / her exacl share of interest?
If name on record is different lhan ihat of
of mortgagee or contract seller
Key number / legal description I Record number O
� / oO C ���� Page number � � ��
J
Mortgage / Contract indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
�5 00
If owned with someone other than spouse, indicate with whom.
- D-Cb?-�0/- 6d0•�/%`'���
ant, indicate below: Is the property in question:
of mortgagee or contracl seller (number and street, city, state,
assignee or other owner or holder oi mortgage
Address of assignee (number and street, city, sfate, ZIP
Does applicant ow
county in Indiana?
20
approv�
Drawer NO. � �`.-..7.7.�5
Card NO . .....................
20 �_ 20 �� 20 OJ
P P
County Auditor
I�A D
What Taxing District?
AUDITOR
20
❑ Real Properly ❑ Mobile Home QC 6-1.
Has this deduction been requested on
property for current year? � Yes� No
20
Date
20
certity under the penalty of perjury that the above and foregoing information is true and corred and that lhe applicants was / were
ent of Indiana and owner of ihe aforemenlioned property on March 1, 20
Signalure (owners fu�l/l name)
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Fi11f iesitlent addEess of applicant
c� �:�.. � �:,�.s�
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person