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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Stata Fwm a3709 (RS / 4-03)
PrescnDeE by Departmem o/ Local G6vemment Finance
Coun Township Year
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INSTRUCTIONS: APR 2 F�� L�J��
To be filed in person or by mail with the CountyAuditor of the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 months be%re May 11 of the year the deduction is to be e/lective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 75 and March 2 o)the yeari�l��du tc�Op��s to be eHective.
See reverse side /or additional instructions and qualifications. GIBSON C UNTY AUpITOR
Applicant (avqer or contracf
Key number / legal descriplion
�1 q -� a �^i-c�
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Page number
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Assessed value of real property as of Mortgage / ContraU indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March t, current ear owner? ❑ Yes ❑ No
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If no, whai 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, indicale below: Is the property in question:
� ❑ Real Properry ❑ Mobiie Home pC 67.1-n
of moAgagee or contracl seller
Address of mortgagee or contract seller (number and st�eet, city,
y
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP code)
Does applicant own property in any olher I If yes, what county?
county in Indiana?
Deduction approved in the amount of:
20 20 O 20
1
Signature
ZIP
What Taxing Distrid?
COUNTY AUDITOR
20 � I 20
� I P
County Auditor
Has this deduction been requested on
property for current year? � Yes � No
20
Date
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We ify under the penalty of perjury lhat Ihe above and foregoing information is Irue.and corred and that the applicants was / were
�esi ent of Indiana and owner of ihe afoy�mentioned property on March 1, 20
full
Person authorized by duly executed Power of Attorney
or by IC 6-7.1-12-.07
of authorized person