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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� S-M� / State Fwm a3709 (R5 / 4-03)
� PrescnUed Dy Depanment ot Local Govemment Finance
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INSTRUCTIONS: Filp�,�`�
To be �led in person or by mail with the County Auditor of the county where the property is loca[ed. SE P 2 q LUU�
Filing Dates: i) Real Property: During the 12 months be/o2 May 110l the year the deduction is to e effective. �
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ t year the d6tluqtien is to e e ctive.
See reverse side for additional insfructions and qua/fications. �J`i�{ "
GIBSON COU� � �' �.UD:TOR
(owne� or contqact
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Assessed value of real property as �
March 1, currenl year
If no, what is his / her exact share of interest?
number / legal
Record number � �
/'� O/_^� � I I C �,O I Page number �^��
lJ �D J--E.J %
Mortgage / Contrad indebtedness unpaid as of
March 1, nt year � /j�QSQ
/ � � � � , �
If name on record is different than ihat of applicant, indicate below:
�eme of mortgagee or conhad seller �
Address of mortgagee or conVad seller (number and street, city, s
Name of assignee or other owner or holder of mortgage
(number and street, city, state, ZIP code)
� - — - --ryv
� Drawer NO ................... T
Is the applicant the sole legal or equitable
owneR ❑ Yes ❑ No
If owned wilh someone other lhan spouse, indicate with whom.
ZIP
Is the property in questian:
❑ Real Property ❑ Mobile Horne QC 61.1-�
D`6-�P`l
What Taxing Distrid? Has this deduction been requested on
property for wrrent yea�'? Q Yes ❑ No
Card NO. �,3 - `�' � � Z' C�
y/_ � L�) Q COUNTY AUDITOR
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20 � b�l 20 0?
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Signature
20 Q(� � 20
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County Auditor
20 _p� � 20
Date
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We certify under the penalty of peryury that the above and foregoing information is We and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
c , '
Person authorized by duly executed
or by IC 6-1.1-12-.07
resident adiiress of 5�pticant � , �Address of authorized person