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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' ' FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
�, «� � State Forma3709 (R4l f0-01) _ � {�
� PrescTibed by Depanment of Loral Gcvemmen� Finance 4 � t' ��
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iNSrRUCrioNS: E�LM�*6 2003
To be filed in person or by mail with the County Auditor o/ the county where the property is located.
Filing Dates: 1) Real Property: During the 12 monfhs be%re May 11 of the year the deduction is to be efled v/ e.
2) Mo6ile Homes assessed under IC 61.1-7: Between January 15 and Ma�ch 31 0l the yea�the�,deductio� is t�o�� ecf v.
See reverse side for additional instructions and qualificafions. � GIBSON COUNTY AUDITOR
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Distrid
Assessed value ofrealproperty as of
March 1, curtent year
no, what is his / her exad
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Key number / legal description
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Mortgage / Contrad ir
March 1, current year
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applicant, indicate below:
Record numbe��
Page number /_ �
ss unpaid as of Is the applicant the sole legal or equitable
owneR ❑ Yes ❑ No
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If owned with sameone other than spouse, indicate with whom.
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Addre `��C� iumber and st2et, city, state,
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Name „__,., ..�� �er awner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applipnl own property in any other If yes, whal county?
county in Indiana?
Deduction approved in the amounl of:
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Signature .
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❑ Real ProperN ❑ Mobile Home
What Taxing Distrid? Has this dedudion been requested on
property for cunent yeaR� Yes� No
COUNTY AUDITOR
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County Auditor
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Date
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/ We certify under the penalty of perjury that the above and foregoing informalion is true and corred and that ihe applicants was / were
i resident of Indiana and owner of lhe aforementioned property on March 1, 20
of
Person authorized by duly executed Power
or by IC 6-1.1-12-.07
n n Address of authorized person
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