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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
f � FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
�. w / State Fom: a3709 (RS / 6-03) ��
� PrescnDeE by Department ot local Gdvemment Finance
iNSrRUCrioNS: MAY ��i@n�g5
To be filed in person or by mail with the CountyAuditor of the county where the property is located.
Filrng Dates: 1) Real Property: During the 12 months 6elore May 11 of the year the deduction is to be eNe
2) Mobile Homes assessed under IC 6• 1.1J: Between January 15 and March 2 0( the year t��t� � be effective.
See reverse side /or additional insfructions and qualifications. GIBSON COUNTY AUDITOR
Appliwnt (owner orcontracf buyer- see restnctions on reverse side)
Taxing Distrid Key number / legal scription Reco number
Page number
�- aao -o
Assessed value of reai property as of Mortgage / Contract indebtedness unpaid as of Is the appli�
March 1, current year March 1, wrrent year owner?
no, what is his / her exact share of interest?
If name on record is
Address o(
than that of applicant, indicate below:
or coniract seller
� �
a�s �
: sole legal or equitable
fes ❑ No
If owned with someone other than spouse, indicate with whom.
or contrad seller (number and street, city, sfate, ZIP
Name ot asslgnee or other owner or holder of mortgage
Address
street, city, state, ZIP code)
riini� �
Does applicant own property in any other I If yes, what county? What Taxing Dir
county in Indiana?
Deduction approved in the amount of:
20
Signature
�
COUNTY AUDITOR
20 20 0 20
P P ��
County Auditor
_ a.�„n�,
property ii
al Property
❑ Modle Home QC 61.1-�
D�aWer �r� �� : a7� d
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20
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We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March t, 20
�nat e owners (ull name) Person authorized by duly executed Power of Attorney
01 7.CM �, i7�WYYU/-1 or by IC 6-1.1-12-.07
7ress of applica t Address of authorized person
�w,'�ST. �.0_�3t3 So��P�u;IIQr�1