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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Siate Porm a3709 (R4 / 10.07)
PrescribeC by Depailrt�enl of Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o! the county where the property is focated.M
Filing Dates: f) Real Propedy: During the 12 months belo�e May 71 of the year tbe deduction is to BQ��lecti�. 2��2
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 the year the deduction is to be effective.
See reverse side Ior addifional instructions and qualificafions. ��
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GIBSON C����(t; � �UOITOR
Applicant (own or ontract buyer- see 2strictions on verse side)
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Taxing Distrid Key number / legal descriplion Record number ��
� �� �O - 035 s a- oa Page number �-� �
sessed value of real property as of MoRgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March i, current year March 1, current year G"') 2 n� 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:
❑ Real Property ❑ Mobile Horne (IC 61.1-�
�me of mortgagee or conlred seller '
Address of mortgagee or contract seller (n b and st2et, cit , state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and streef, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has lhis deduction been requested on
county in Indiana? property for wnent yeaf? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 �_ 20 20 20 � 20 20 � �
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Signature County Auditor Date
/.We certify under the penalry of perjury that the above and foregoing iniormation is true and corred and that the applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owne/s (ull name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full resident address of applipnt Address of authorized person