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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSEO VALUATION Coun Township Year
's / State Fwm a3709 (RS / a-03) � , . .
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� Presaibetl Ey DepaRment of Local Govemment Finance
�NSrRUCnoNS: � 2 2�g Ma�
To 6e filed in person or by mail with the County Auditor of the county where the property is located. FEB
Filing Dates: 1) Real Property: During fhe 12 months be%re May 11 0/ the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the keal,t�e de�'on is to be eNective.
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See reverse side for additional instructions and qualifications. TY A�p�TOR
GIgSON COUN
(owne� or
Assessed value of real
March 1, current year
buyer- se restrictions on reverse sid )
Key number / legal descr
n /%1' � _ _ /1 ��
as of I MoRgage / Contrad ii
March 1, current year
no, what is his / her exact share of
If name on record is different than that of applicanl, indicate
of mortgagee or contrad seller
Record number D
Page number _ ,
�� � .
unpaid as of Is the applicant the sole legal or equitable
owner? ❑ Yes ❑ No
if owned with someone other lhan spouse, indicate with whom.
Address oi mortgagee or contraIX seller�r(um6er and st�et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP code)
Is the property in question:
❑ Real PropeAy ❑ Mobile Home (IC 61.1-�
Does applipnt own properiy in any other I If yes, what county? `What Taxing Distrid? Has this dedudion been requested on
counfy in Indiana? I property for current yea(? � Yes � No
Deduction approved in ihe amount of:
20 20�_ 20
� � `
Signature
COUNTY AUDITOR
20
County Auditor
20
�
Date
20
certify under the penalty of pery'ury that the above and foregoing information is true and correct and thal the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
�ers lull name)
a d /"� . �il� O
Person authorized by duly execuled Power of Attomey
or by IC 6-1.1-12-.07
Address of authorized person