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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
" FOR DEDUCTION FROM ASSESSED VALUATION
� .J State Fam d3709 (RS / 4-03)
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Prestn�etl by Departmem of Local Govemmeni Finance
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INSTRUCTIONS: � �
Coun Township Year
File Mark
To be filed in person o� by mail with the CountyAuditor o)the county where fhe property is located. ��f �.J � s ZQQS
Filing Dates: 1) Real Property: Dunng the 12 months be(ore May 11 0/ the year the deduction is to be effective.
2) Mo6ile Homes assessed under IC 6-1.1J: Between January 15 and March 2 0l the year t�re,deductioy i,5to be eHective.
See reverse side for additional instroctions and qualifications. ���� '� yU
GIBSON COUNTY AUDITOR
Applicant (owner or contracl buyer- see restnctio on reverse side)
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Taxing DistriC Key number / �egal description Record number Q J_ 3�C�
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O/ � _ � � /4 � S ��/ �/ Page number
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicantrrr ���the sole legal or equitable
March t, current year. _ March 1, wrrent year ownef? �r�s ❑ No
SO 6 �
If no, what is his I her exact share of interest? If owned with someone other than spouse, indicate with whom.
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If name on record is diHerenf than tliat ot applicant, indicate below: Is the property in question:
PropeAy ❑ Mobile Home (IC 61.1-�
�me of mortgagee or contrad seller
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' Address of mortgagee or coniract seller (number and st�eet, city, state, ZIP
Name of assignee oi other owner or holder of mortgage �{-�—� --'
Address of assignee (num6e�and st2et, ciry, state, ZIP code) � �I A � 1� L�r1ILKC ��
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Does applicant own property�in any other If yes, what county? What Taxing sC �� ��' �� �� n
counry in Indiana? OS ' J SS.3 Vo
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 �a_ . 20 �� 20 20 20 20
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SignaWre Counry Auditor Date
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We certify under the.penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March t, 20
Signature (owners lull name) Person authorized by duly executed Power of Attomey
' L or by IC s-t.t-lz-.o7
F residenl address of applicant Address of authonzed person
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