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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR OEDUCTION FROM ASSESSED VALUATION Coun Township Year
�'. � ! State Fortn a3709 (R5I4-03) _
w.
� PrescnDed by Department of Loral Govemment Finance
INSTRUCTIONS: IY p 'E � DULY ENTEi�9 ��TPJ{ATION
To be filed in person or 6y mail with the CountyAuditor of the c�ty where the property is locatedSub'e t t final acceptance for transfer
Filing Dates: 1J Real Property: Dunng the 12 montbs before May 11 o(j,i� yqa�th�¢uction is to be ef�GC�iv����Pr1���a
2) Mobile Homes assessed under IC 6-1.1-7: Between .1�i�1)�r�l'1 an`� March 2 0/ they�eef(ll��
See reverse side for additional instructions and qualifications.
j� �'JJ� ,�/�, � ,�r�i-c� Auditor
1 / . _.__...,...:��.irv eiinlTOR � � GibsonCounty
(owner or contract
Distrid
Assessed value ofreal
March 1, current year
see
as of
no, what is his / her exact share of interest?
m
Key number / le�al desc�tj6n Record number O�
o � � %ba -�� Page number ,j,
� �.g�
Mortgage / Contrad indebledness unpaid as of Is the applicant the sole legal or equitable
March 1�carCent Vear owneR ❑ Yes ❑ No
If name on record is different than lhat of applicant, in
�e of mortgagee or contrad seiler `
�h� � �
Address of mortgagee or contraIX seller ( umber and
of assignee or other owner or holder of mortgage
of assignee (numberand st2et, city, sfate, ZIP
city,
If owned wilh someone other than spouse, indicate with whom.
Does applicant own property in any other I If yes, what county? What Taxing Distrid?
county in Indiana?
Dedudion approved in the amount of:
� j%�
Signature
20 �
COUNTY AUDITOR
20 �_ 20 �_ 20
�
County Auditar
❑ Real Rnperty � Mobile Home (IC 61.1
S
Has this dedudion been requested on
property for current year? �] Yes❑ No
20
20
We ceriify under ihe penalty of perjury that the above and foregoing information is true and corred and that the appiicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
S�a►o a.
Q.3 gox 111 o�NSv�u� � G16(�$
Person authorized by duly executed Power
or by IC 6-1.1-12-.07 .
of authorized person