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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Farm a3709 (RS I 4-03) ,
PresaiD�W Dy Department of Laal Govemment Finance
INSTRUCTIONS:
To 6e filed in person or 6y mail with the County Auditor of the county where the property is locafed. MAR 1 4 2�05
Filing Oates: 1) Real Property: During the 12 months 6efore May 11 of the year the deduciion is to be ef(ective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 oIlhe year the deduction is to be effective.
See reverse side /or additional instructions and qualifications. �� ��
�'y � /� _ I{� ,/ � /� � /_��� GIBSON COUNTY AUDITOR
lJ V� CJ K�
Applicant (owner or contracf 6uyer - see restrictions on reverse side) _
Taxing Distriq
Assessed value of real property as of
March 1, curtent year
If no, what is his / her exact share of
Key number / legal description Q I Record
Page number
3 ' O �
Mortgage / Contract indebledness unpaid as of Is lhe applicant the sole legal or
March 1, current year owneR [�s ❑ No
� . ,� _ _ �
owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
e of mortgagee or contraU seller
_ � _ ��- -�-9 .���
Address of mortg e or contrad selier (number and st2et, city, state, ZIP
Name of assignee or
Address of
owner or holder of mortgage
(num6er and street, city, state, ZIP code)
Does applicant own property in any other I If yes, what county?
county in indiana?
Deduction approved in the amount of:
20
Signature
20 �
�
Taxing
COUNTY AUDITOR
20 _� 20 � 20
P P
County Auditor
Is the property in question:
❑ Mobile Home
Drawer NO. ��:... ��p.�
Card NO . .....................
Cr1.1
on
pwyci�y �vi wnci�� �....� : � . __.� NO
20
Date
20
certify under the penalty of perjury lhat the above and foregoing information is true and correct and that the applicants was / were
lerxof Indiana and owner of the aforemenlioned property on March 1, 20
full
ISL�J
applicant
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Address of authorized person