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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm a3709 (R5 / a-03)
PtascnbeE by Department of Local GovemmeM Finance
Coun Township Year
�RUCTIONS: Fite�Mark
oe filed in person or by mail with the County Auditor of the counry wheie the property is I� d� � ��
Filing Dates: i) Rea/ Property: Dunng the 12 months before May 11 of the year the deductio�is to be eflectiv_e�/
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the year the deduction is to be effective.
See reverse side for addilional instructions and qual�cations. N 0 U Q`] 2��3
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Applicant (owner or contract buy - e restnctions on re e e side /,��J`�/��`^�'�,4 �
GIBSON CO!�N7�" AUDITOR
Taxing District Key number / legal description Record number
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� _ QO/��('/ agenumber � �
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? ❑ Yes ❑ No
I( no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Hotne (IC 61.1-7)
Name of moAgagee o contract seller
�ress of mortgagee or contrad seller (number and street, city, state, ZIP
( 1� C
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, ciry, state, Z/P code)
Does applicant own property in any other If yes, what counry7 What Taxing District? Has lhis deduction been requested on
counry in Indiana? property for curtent year? ❑ Yes � No
COUNTY AUDITOR
Deductlon approved in the amount of:
0 20 20 � 20 �� 20 o Y 20 D i 20
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Signature Counry Auditor Date
I/ We certify under the penalty of perjury Ihat the above and foregoing infortnation is true and corzect and that the applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
' ature (owner's full name) Person authorized by duly executed Power ot Attomey
or by IC 6-1.1-12-.07
ull resident address ot applicant l{7 6 S' Address of authorized person
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