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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�'+ � / Stata Fwm a3709 (R5 / 6-03)
� PrescnDed by Depenment of Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year fhe deduction is to be effectiv� � � �% 2��3
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/the yearlhe deduction is to be elfective.
See reverse side Ior additional instructions and qualifications. � �y/ .-�.{ /��f
GIBSON� 7�� i��i�R �
Applicant (owner or contract buyer - see restrictions on reverse side)
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Taxing District Key number / legal description Record number
3
�— (� QQ ! � Q l Page number
C�.�l�RSA� b �
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? �Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
Properry ❑ Mobile Home (IC E1.1-7)
'�me of mort agee or contract seller
C, � � C
Address of mortgagee or contract seller (number and street, city, state, ZIP
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Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, ciiy, state, ZlP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for curcent year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 Q� 20 O r 20 n�: 20� 20 � 20 20
f' P
ignature Counry Auditor Date
! We certify under the penalry of perjury that the above and foregoing information is true and correct and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Signa owner's ful� ) Person authorized by duty executed Power of Attomey
or by IC E1.1-12-.07
I resi nt a dress of applicant Address of authorized person
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