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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Siate Fom� a3709 (RS / 4-03)
PrescriEed by Depanment of Laal Govemment Finance
Coun Township Year
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the county where the property is located. A P R 1 3 20Q5
Filing Dates: 1) Real Property: During the 12 montAS before May 11 0/ the year the deduction is to 6e effective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 2 of the ye�,t�dedu�n is to be effective.
A�< ,!S
See reverse side for additional instructions and qualifications.
GIBSON COUNTY AUDITOR
(owner or confract buyer - see stnctions on ieverse side)
t„ rm .� �'�' � prn �.,. . � n�
number /
� � 1
�{� � /� � _ O �O � � _ � Page number
A,CYY�J �I
Assessed value of real property as of Mortgage / Coniraci indebledness unpaid as of Is the applicant the s legal or
March 1, wrrent year March 1, current year owne(? es ❑ No
Ii no, what is his / her exact
If name on record is different than ihat of applicant,
of mortgagee or
-II
below:
If owned with someone other than spouse, indicate with whom.
Address of mortgagee or coniract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of moAgage
of assignee (number and st2e(, ciry, state, ZIP code)
Does appliwnt own property in any other If yes, what county? What Taxing Distrid?
county in Indiana?
S� �� a � COUNTY AUDITOR
Deduction approved in the amounf of:
20 20 20 �
� �
Signature
20
County Auditor
�
Is t
❑
O Mobile Horrie (IC 61.1-�
Has this deduction been requested on
property for current year? �] Yes � No
20
Date
20
certify under the penalty of perjury that the above and foregoing information is true and correct and lhal lhe applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Atlomey
or by IC 6-1.7-12-.07
authorized person