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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sute Fortn a3709 (RS / 4-03)
PresaiDed by Department ot Loral Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail wilh the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months befo2 May 11 0/ the year the deduction is to 6e e.�,�Tjv� 9 2005
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and MarcA 2 0/ the year the deduction is to 6e eflective.
See reverse side for additional instructions and quali�cations. �i
GIBSON Cp�N�� �nR
Applicant (owner or
S�
Taxing Disirid �
Assessed value oi re�
March 1, current year
buyer ^see restri9hyrf,s on reverse side)
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K.C.f�
�perty as of
If no, what is fiis / her exact share of inierest?
number / legal description Record number
05 -/
O`, _ �� � I � Page number
Mortgage / Contrad indebtedness unpaid as of Is the applicant the e legal or equitable
March 1, current year owner? es ❑ No
vd
If owned with someone other than spouse, indicate with whom.
name on record is different than ihat of applicant, indicate
of moRgagee or conlrad seller
of moAgagee or contred seller (number and street, city, state, Z!P
assignee or other owner or holder of mortgage
of assignee (num6er and street, city, state, ZIP code)
Does appticant own property in any olher I If yes, what county?
county in Indiana?
Deduction approved in the amount ot:
20 � 20 O'
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Signature
What Taxing District?
COUNTY AUDITOR
20 �7�' 20 � 20
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County Auditor
s theg� perty in ques[ion:
lCReal Property ❑ Mobile Home (IC 61.1-�
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Has this deducfion been requested on
propeAy for current year? � Yes � No
20
Date
20
We certify under the penalty of perjury that the above and foregoing information is true and corred and thal lhe applicants was / were
�esident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person