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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
S / State Fwm a3709 �R5 / a-03) - .
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� Prescribed by Department of Lofal Govemment Finance
Coun Township Year
�
INSTRUCTIONS: MAY ���D
To be filed in person or by mail with the County Auditor of the county whe�e the property is located.
Filing Dates: 7J Real Property: During the 12 months 6efore May 11 0! the year the deduction is to be e e tive.
2) Mobile Homes assessed under IC 6-7.1J: Between January 15 and March 2 of the year(h �uaf�o �to be effective.
See reverse side /or additional instructions and quali�cations. GIBSON COUNTY AUDITOR
Applicanl {o}tqero%confract buyer-see
Taxing Distrid
Y �%O i`-'
Assessed vatue of real property as of
March 1, current year
side)
/ legal description � Record number
/ OOb
�/ �^ �/ / ,�/ �_ � Page number
C,/ T 5 02
Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or
March 1, current year ownef? ❑ Yes ❑ No
�� _ � ��, �0�
If no, what is his / her exact share of interest?
If name on record is different than fhat of applicanl, indicate below:
of mortgagee or contrect seller
��c
owned with someone other than spouse, indicate with whom.
Address o( moRgagee or contrad selier (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Dces applicant own propeRy in any other I If yes, what counry? I What Taxing District?
county in Indiana?
COUNTY AUDITOR
Deduction.app%�ed in the amount of:
� � i' C1 — -
20 C Q'~ �� . 20 20
Drawer NO......... �J
9 a5�/ .... , , A�d��o�
Si nat Card N� . .....................
�saacv
s the property in
❑ Real Property ❑ Mobile Home QC 61.1-�
Has this deduction been requested on
property for current year?� Yes❑ No
ZO
Date
20
We certify under the penalty of peqwy ����, ,.._ _ and foregoing information is true and corred and that ffie applicants was / were
�es�lent of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-7.1-12-.07
of authorized person