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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 03709 �R6 / SO6)
Presaibed by Deperlmenl of Lo�l GwemmeM Finance
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INSTRUCTIONS: File M rk
To be filed in person o� by mail with the County Audito� of the county whe�e the property is located. N � � � 0 2��6
Filing Dates: 1J Real P�operty: During the 12 months before June I f o! the year the deduction is to be effective.
2) Mobile Homes assessed under lC 6-1.1-7: Between January 15 and March 2 of the year the dedtrclian is t�ective.
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See reverse side for additional instructions and qualKications. U
GIBSON COUNTY AUDITOR
Applica (ownerorcontrac �er- see restncfions o rever� side) '
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Tauing Distrid Key number / legal description Record number
G-�9- iP 3oi-000. y�s� o� Q�o
�� � � I I- D D 4� 4- UD Page number
Assessed value of real property as of MoRgage / Contract indebtedness unpaid as of Is the appliqnt the sole legal or equitable
March 1, current year March 1, current year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interes!? 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 Property ❑ Mobile Horne pC 61.1-�
me ot mortgagee or contract selier
Address of mortgagee or contract seller ( ber and st�eet, city. state, ZIP
Name of assignee or other owner or hol er f mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does appliwnt own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requesled on
county in Indiana? property for wrrent year? � Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �Z 20 � 20 20 20 20 20
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Signature County Auditor Date
�/ We ce ' under lhe penalty of perjury that the above and foregoing information is true and corred and ihat the applicants was / were
a resi t of Indiana and owner of the aforementioned property on March 1, 20
ture wne s lull nam ) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full re �d nt address of applipnt Address of authorized person
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