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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
F FOR DEDUCTION FROM ASSESSED VALUATION Coun Township I Year
�• w� / State Form a3709 (R5/4-03) �
� Prescn�etl by Department of Laal Govemment Finance
INSTRUCTIONS: MAY Fil���5
To be /iled in person or by mail with the Counry Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 72 months belore May 11 of the year the deduction is to be efleativ /�
2J Mobile Homes assessed under IC 6-1.1-7: Between January 75 and March 2 of the year th�B6�l6n �s�`(�'be effective.
See reverse side Ior additional instructions and qualificafions. GIBSON COUNTY AUDITOR
Applicant (owner or contrac!
Taxing Distrid
see resfrictions on reverse side)
Key number / legal description
number
p 3
Page number
��� � c� - o( co� t- oo � 0 8$
Assessed value of real property as of Mortgage / ConlraG indebtedness unpaid as of Is the applicant t e sole legal or equitable
March 1, current year March t, wrrent year owner? es ❑ No
t"�l5 bo
If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicanl, indicate below: Is ihe property in question:
of mortgagee or contract seller
of moRgagee or contract seller (number and sf2et, city, slate, ZIP
of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP
Does applicant own property in any other I If yes, what county?
county in Indiana?
Deduction approved in the amounf of:
20 0 �a
Signature
20
What Ta
COUNTY AUDITOR
20 � 20 20
l
County Auditor
❑ Mobile Home (IC 61.1-�
D �' �a • • •� �uested on
Dra���er NO ............... o� � Yes❑ No
Card N� •%•���'....
20
Date
T�7
' We certify under the penalty of perjury thal the above and foregoing information is true and correct and that the appiicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
name)
-�c��- � J7�--�
Fuil resident address of applicant
�3 Qo�L-10� ��Z��.c�'oti �SSV
,i 0
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Address ofaulhorized person