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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�. «. �! Sute Form a3709 (RS / 4-03) - . � � �
� PrescnDetl by Departmeni of Local Govemmenl Finance
�rvsrRUCnoNS: NOV 22 2�Q�Ma�
To be filed in person or by mail with the County Auditor of the county whe�e [he property is loc ed.
Filing Dates: 1) Real PropeRy: During the 12 months be%re May 11 0/ the year the deductio to be ffe� ive.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 yee�,�iEt,�� eflective.
See reverse side for additional instructions and qual�cations.
GIBSON COUM Y AUDITOR
resMctions on reverse side)
Taxing Distrid
Assessed value of4eal property as of
March 1, current year
no, whal is his / her exad share of interest?
Key number / legal description Record number �!�
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Q�s— GL� �a -� Page number 2� /
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MoAgage / Contract indebtedness unpaid as of Is the applicant th sole egal or
March 1, current year owneR Yes ❑ No
If owned with someone other than spouse, indicate with whom.
If name on record is different lhan that of applicant, indicate below:
�re of mortgagee or contra seller
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Address of mortgagee or contract seller (number and street, city, stale, ZIP
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Name of assignee or other owner or holder of mortgage _ _
Address of assignee (num6er and stieet, city, state, ZIP r
Does applicant own property in any other If yes, what cc
county in Indiana?
y
Deduction approved in the amount of:
Z�Q� 2� � I 2� OB
/✓
Signature Count�
e certify under the penalty of perjury that the aF
sident of Indiana and owner of the aforementic .
Sianature (ou�ners (hll nameln .
� 3 I3�- �0 2 0
Is the
❑ Mobile Hmie (IC 61.
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� . � ..�a Power of Attomey
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Address of authorized person