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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
� i� FOR DEDUCTION FROM ASSESSED VALUATiON
�: ,�'y State Fwm. a3709 (R5 / a-03)
P2scn�ed by Depanment of Local Government Finance
�
INSTRUCTIONS:
To 6= filed in person or by mail with the County Auditor of the county where the property is located. SE N 1_ 2��3
Filing Dates: 1) Real Property: During the 12 months befo�e May 11 o7the year the deduction is to 6e e/)ective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year t�on'is t��ll ve.
See �everse side (or additional insWctions and quali(cations.
"' GiBSON CGUNTY AUDITG; I
Applicant
buyer- see restrict�s on reY�s�side)
Asse s�ti value o( real property as of
March t, current year
If no, what is his / her exact share of interest?
Key number l legal description Rewrd number O ,
DO LI � QO ��q /��� Page number ��
b �
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate below:
Name of mortgagee or contract seiler
i �13
Address of mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or olher owner or holder of mortgage
,\ddress o( assignee (number and street, cify, sfate, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid?
county in Indiana?
COUNTY AUDITOR
Deduction approved in the amount of:
20 �� I 20 !9(/i I 2p �_ I 20 �`� I 20 ��
� I � �
_ County Auditor �
Is the propeAy in queslion:
❑ Real PropeAy ❑ Mobile Home QC 61.1
Has this dedudion been requested on
property for curren� year?�] Yes❑ No
20
Date
C��
/ We certify under the penalty of perjury that the above and foregoing information,is true and corred and that the applicants was / were.
`esident of Indiana and owner of the aforementioned property on March 1, 20
applicant
Person authorized by duly executed Power o( Aftorney
or by IC 6-1.1-12-.07
of authorized person