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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm a3709 (RS / 4-03) '
PresaiEed by Depanment of local Govemment Finance
INSTRUCTIONS:
To 6e �led in person or 6y mail with the CountyAuditor of the county where the property is located. J�N 2 1. Z�04
Filing Dates: 1J Real Property: During the 12 monfhs 6e%re May 11 0l fhe year the deduction is to be eflective.
2) Mobile Homes assessed under IC 6-1.7-7: Between January 15 and March 2 0/ the e�uctyiori i�� eflective.
See reverse side !or additional instructions and qualifications � J-1 :
Gi9SON COUt.�T'! q�p;TC�
orcontracf
Tauing
Assessed value of real property as of
March 1, wrrent year
If no, what is his / her exact share of interest?
If name on record is different than that of
of mortgagee or contract seiler
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Key number / Iegal description l � � Record number
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(p - U CJ Page number ! /
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Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or
March 1, current year owneR ❑ Yes ❑ No
Address of mortgagee or contract seller (number and street,
Name of assignee or other owner or holder of morigage
below:
Address of assignee (num6erand stmet, city, state, ZIP code)
Does applicant own property in any other I it yes, �.�hat wunty?
county in Indiana? �
Deductior
20 0 5
I-
Signature
Dra�r�er NO ...................
Card NO. ��`" - `�` �a 7"
....................
owned with someone other lhan spouse, indicate with whom.
state,
Il'Jhat Tzxing District?
NTY AUDITOR
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County Auditor
Is the property in question:
❑ Real Property ❑ Modle Horne (IC 61.
Has ihis dedudion been requested on
propeAy for current yeaC�� Yes❑ No
zo
Date
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/ We ceAify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
� resident of Indiana and owner of the aforemer.tioned property on March t, 20
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address of
0
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
ofauthorized person