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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VAIUATION
State Fortn a3709 (RS / 4-03)
Piascnbed py Depanmeni ot Laal Govemment Finance
Coun Township Year
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rrusrRUCnoNS: FEB 1 b�i�p�
To be filed in person or by mail with the County Auditor of the county whe�e the property is located.
Filing Dates: 1) Real Property: During the 12 months 6e%re May 11 of the year the deduction is to be e!� ve. y
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year"the�d��imiys to be e/fective.
See 2verse side 1or additional instructions and qualifications. GIBSON COUNTY UDITOR
or contract
value of real property as of
March 1, curtent year
reverse side)
Ke number / legal descri tion Record number
��-i�-o�-�oa-Soa.yqs-ba o �
O / _O - � Page number ��
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year � owner? � Yes ❑ No
Ii �o, what is his / her exact share of interest?
If name on record is different than thaf oi applicant,
of mortgagee or contrad seller
below:
Address of mortgagee or contrad seller (numb nd stieet, city,
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, sfate, ZIP code)
Does applicant own property in any other If yes, what county?
county in Indiana?
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Signalure
approved in the amount of:
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20 Q�
1
owned with someone other than spouse, indicate with whom.
Is the property in question:
❑ Real Property ❑ Mobile Home (IC Cr1.1-�
ZIP
What Taxing DistriIX? . �Has lhis deduction been requested on
property for currenl year? � Yes ❑ No
COUNTY AUDII �� ' .
02��'- acS O
20 � G y OL�t�. I=�C U'� �� �l6p.�c —
County Auditor
Date
certify under the penalty of perjury thal the above and foregoing information is true and correct and that the applicants was /were
lent of Indiana and owner of the aforementioned property on March 1, 20
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Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
resident aAdress of app�icant �Address of authorized person