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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�'• «� / Slate Fortn a3709 (RS / 4-03) � � .
� PrescnDed Dy Department of Local Govemment Finance
To beR�UC�TION �on or by mail witb the County Auditor of fhe county wbere the property is located.� ��il���
Filing Dates: 1) Real Property: Dunng lhe 12 months befo2 May f i of the year the deduction is to be eflective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/the year tfr��f�ufti� '��e effective.
See raverse side Ior additional instnrctions and qualifications.
/1 ,. �laH, ��
Applicanl
GIBSON COUNTY AUDITOR
Key number / legal desuiption � Rewrd number
/ �/g�Da���:-O� � Pagenumber ^I��
r
Assessed vaiue of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March,l, curtent year March 1, current year . owner? ❑ Yes ❑ No
'�k�OC�o '
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate wilh whom.
name on record is different Ihan lhat
of mortgagee or contract
indicate below:
Address of mortgagee or conVad seller (number and
Name of assignee or other owner or holder ot mortn�^-
Addres� ^` �
-����8�
Does ap,
county in 0 d�� ��'
�j
le)
?
ZIP
What Taxing District?
COUNTY AUDITOR
Jedudion �Nproved in the amount of:
20 �Z, 20 �$_ 20 � 20
P P �°
Signature
Coun�y Auditor
20
s the property
❑ Real Property ❑ Mobile Hane (IC 61.1-�
Has this dedudion been requested on
property for current year? � Yes 0 No
20
Date
20
We certify under the penalty of perjury that the above and foregoing information is true and corred and lhat lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
llull name)��/
9 `-'/�\
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
I resident address o( applicant - � Address of authorized person
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