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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sfate Porm a3709 (Ra / 10-01)
Prewibed 6y Deparimen� ot Loral Govemment Finance
Coun Township Year
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� INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the counfy where the propeRy is located. F E g � 6 2�03
Filing Dates: 1) Real Prope�ty: During the 12 months be(ore May 11 of the year the deduction is to be�effective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Behveen January 15 and March 31 of the( ye�ar the �de,, uctl7o�n i�s to/p� e Bctive.
See reverse side for additional ins(iuctions and quali�ca6ons. /��`^"'``�%'� ��`�^ ^^-�
G:BSON COUNTY ��UDITOR
Applicant (o er or contract buyer - see restricti ns on reverse side)
Tauing Distrid Key number / leg escription Record number
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• � Page �umber
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Assessed value of real property as of Mortgage / ContraC indebtedness unpaid as of Is the applican t�sole legal or equitable
March t, current year March 1, current year � N]' b 6p � owneR es ❑ No
If no, what is his / her exact share of interest? I( owned with someone other than spouse, indicate with whom.
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If name on record is diHerent ihan that of applicant, indicale below: Is the property in quesiion:
eal Property ❑ Mobile Hane (IC 61.1-�
me of mortgagee or contrad seller
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Address of mortgagee or contract seller (number and street, city, state, ZIP
. 07-43
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applipnt own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for curtent yea(? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of: / �
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20 � 20 O 20 �/_ 20 20 20 20 �
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Signature County Auditor Date
/ We cerfify under lhe penalty of perjury thal the above and foregoing information is true and corred and ihat the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (own I na Person authorized by duly executed Power of Atlomey
or by IC 6-1.1-12-.07
Fu resident address applicant Address of authorized person
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