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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
' : FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
S J State Fortn a3709 (R4 ! f0-01)
PreSttibeE by Department ot Loral Govemmem Finance
INSTRUCTIONS: � � ile � �
To be filed in person or by mail with the County Auditor o/ the county where the property is located.
Filing Dates: 1) Real PropeRy: During the 12 months before May 11 oJ the year the deduction is to be e ectiv .
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 31 0/ the year thgdeductiqn j,�t�O� e ef/ective.
See reverse side /or additional instmr.tinns and nualificatinns � r 4 l
Appli nt wnero contract r-se �esMctio reverseside) GIBSONCOUNit AUpiTOR
(.(.
Taxing Distrid Key ber / legal descnption , Record number Q�
/ , ne .� A , •_, M�+ � ( /� ,�-� Page number //�
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Assessed value of r I roperiy as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, wrrent year owneR ❑ Yes ❑ No
V
Ii no, what is his / her exact share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than lhat of applicant, indicate below: Is the property in question:
❑ Real Property O Mobile Horne (IC 6-1.1-�
me of mortgagee or contrad selier
' � �
Address ot mortgagee or contrect seller (number and stre'et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP code)
Does applicant own property in any other if yes, what counry? What Taxing District? Has this dedudion been requested on
county in Indiana? property for curtent yeaf?�] Yes❑ No
COUNTY AUDITOR
Deduction approved in the amounl of:
20 20 20 20 20 20 �� 20 ��
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Signature County Audifor Date
We ceAify under ihe penalty of perjury that the above and foregoing infortnation is true and corred and that ihe applicants was / were �
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full re pt �dQ' Ir�ss o(app�6 �L 6 Address of authorized person
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