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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�. w� ✓ State Fwm a3709 (RS I 4-03)
� PrescriEed by Department ol Local Govemment Finarice
INSTRUCTIONS:
To be (led in person or by mail with the County Auditor o/ the county where the property is located. �QR 1 5 2005
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 0l fhe year the deduction is to be eBectiv .
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to bQ effective.
See reverse side /or additional instructions and qualifrcations. � ���
GIBSON C� TY AUDITOR
Applicant (owner or co t buyer = see restri 'ons on revers i e)
Taxing Distrid K number / legal description Record number O
� f �� Q ��O�' O age number ^��
�� b (
Assessed value of real property as of Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? ❑ Yes � No
� O
If no, whal is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
, '
If name on record is different than ihat of applicant, indicate below: Is the property in question:
❑ Real Properiy � Mobile Home pC 61.1-�
�e of mortgagee or contrad seller �-
\
Address of mortgagee or contrad seller (number an street, city, state, ZI
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code) .
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current yeaf?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20D (_ 20 �� 20 �g 20 � 20 20 20
-�' P �' ,o
Signature County Auditor Date
We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was ! were
sident of I ana and owner of the aforementioned property on March 1, 20
ignat e� ers 11 naWe) Person authorized by duly executed Power of Attomey
�� or by IC 6-1.1-12-.07
resi ent add s of a plicant _ (� /� � ress of uthorized person
S CR.�..iv� -t `� iU-t • � � (v �