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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
���� J State form e3709 (RS / d-03)
� Pmscnbed by Depanment ot Local Govemment Finance �
INSTRUCTIONS: File Maric
To be filed in person or by mail with the County Auditor of [he county where fhe property is locat��g j 6 Z�0]
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0/ the year the deduction is to e e�jective.
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/th�e- yy�ear the deduction is to be eNective.
See reverse side for additionaf instructions and qualifications. !�'`a� ��`�
GIBSON COUNTY AUDITOR
Applicant (av er or contract 6uyer_see resMctions on reverse
� i.
Taxing Dislrid /i ' `-�
V
� �tia�-- , .
Assessed vatue of real property as of
March t, current year
If no, what is his / her exac[ share of interest?
Key number / legal`�s'cnption Record number
�L-l�.-o�-`�oo-oo/ �r9-o,tt
O�/ S —O / % / 9—C�J � ` - Page number a �
Mortgage / ContraG indebtedness unpaid as of Is the appliwnt the sole legal or e
March 1, wrrent year owner? ❑ Yes ❑ No
" %� S-O�
If owned with someone other than spouse, indicate with whom.
If name on record is different than ihat of applicant,
of mortgagee or contract seller
Address of mortgagee or contraG seller (number and sfreet,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st�eet, city, state, ZIP
below:
Does applicant own property in any other If yes, what county?
county in Indiana?
20 U 1
1
SignaWre _
approved in the amounl
r� �
state, ZIP
properfy in question:
❑ Mobile Home (IC Cr1.
Dra«•er i\'O.. � �� �%
What Taxing Distri Card i\T�, U� � l � �
� �l Cn�, �bi�' .... �o
COUNTY AUDITOR
20 20 20
l'
County Auditor
20
20
certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
`�iQlu �Pi• ��-Qc
resident address o( applicant
5a i� s 95o cJ
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Address of authorized person