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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
i / Siate Form a3709 (RS / d-03)
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� Presaibe0 by Department of Local Govemment Finance
INSTRUCTIONS:
To 6e �led in person or by mail with the CountyAuditor of the county where the property is located. �p 4 2005
Filing Dafes: 1) Real PropeRy: During the 12 months before May 11 of the year the deduction is to b�c�4.+ct�e.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 75 and March 2 of the year the deduction is to be eHective.
See reverse side /or additional instructions and quali�cations. a(�/
GIBSON COUNTY� �TOR
Applicant owner or contract buyer - e restrictions on rever side) ,
Taxing Dis rid ' Key n mber legal description Record number D
��" ""�' 4 00 �� 7 1{"DV Page number r
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Assessed value of real property as of Mortgage / ContreU indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curcent year March 1, current year owne(? ❑ Yes ❑ No
Ii no, what is his / her exact share of inlerest? If owned with someone olher than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
�me of mortgagee or coNrad seiler
Address of mortgagee or contract seller (number and st2et, ty, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deduclion been requested on
county in Indiana? property for wrrent year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in lhe amount of:
2o Zo � zo zo a 9 zo Zo za
� � Jv
SignaWre County Auditor Date
'/ We ify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resi nt of Indiana and owner of the aforementioned property on March 1, 20
tur (ow e/s /ull na ) f. ^ Person authorized by duty executed Power of Attomey
or by IC 6-7.1-12-.07
Full i ent address of appli nl �� Address of authorized person