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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sfate Fortn a3709 (RS / 4-03) ��
PresaiDetl by Depanment ol Local Govemment Finance
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Coun Township Year
DULY ENTE ED'rOR 1'i:�;,qT� N
Subject tc final acczp!a;,ce for
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INSTRUCTIONS: File Mark
To 6e filed in person or by mail with the County Auditor o) the county where the property is loca� ��� � Audi!or
Filing Dates: 1) Real Property: Dunng the 12 months 6efore May 11 of the year the deduction is-to be�e cfi Gibson County
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 d�dh�year the deduction is to be eRective.
See reverse side for additional instructions and qualifications.
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Applicant (owner or ontract buy • see restricti s on rse ' e)
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Taxing District Key number / legal descripti Record nu ber 3
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n� 1 _ �/�� Page number
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Assessed value of real property as of Mortgage / Contrect indebtedness unpaid as oi Is the applicant th sole legal or equitable
March 1, current year March 1, curtent 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 lhe property in question:
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❑47ea1 Property ❑ Mobile Home (IC E1.1-7)
�me of mortgagee or contract sell
Address of mortgagee or contract eller ber stree[, city, stat , ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP 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 tor curreni year? ❑ Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 JL� 20 Q/� 20 20 0� 20 �_ 20
P'ift8o,¢ {� � P
Signature Counly Auditor Date
' I We certify under the penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was / were
�zsident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owner's lull name) Person authorized by duly executed Power of Attomey
or by IC 6-t.t-12-.07
F II res ent address of appl' t Address of authorized person
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