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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm a3709 (R5 / 4-03) �
Presaibed by Department of Local Guvemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county whe2 the propeRy is located. FEB � 1 2�05
Filing Dates: 1) Real Property: During the 12 months betore May 11 0l the year the deduction is to be eHective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year deduction is to be eNective.
See reverse side for additional instructions and qualiTcations. a«[/�.
GIBSON COUN�� �TOR
Applicant (owner or co ract buyer- see trictions on �everse side)
Tauing Distrid Key nu / legal description Record number 1
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�! -{ - oa3 q ��Uv Page number
Assessed value of real property as of MoRgage ! Contrect indebledness unpaid as of Is the applicant the sole egal or equitable
March 1, curtent year March 1, currenl year ownef? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? Ii owned with someone other than spouse, indicate with whom.
If name on record is different lhan that of applicant, indicate below: Is the property in question:
❑ Reat Pmperty ❑ Mobiie Home (IC 61.1-�
�me ot mortgagee or contrad seller
Address of mortgagee or contracl seller (num e and s�, state, Z P
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 District? Has this deduction been requested on
county in Indiana? property for current year? � Yes � No
COUNTY AUDITOR
Dedudion approved in the amount of:
20 20 � 20 20 �� 20 20 20
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Signature County Auditor Date
I We certify u er the penalty of perjury lhat the above and toregoing information is true and corred and that the applicants was / were
esi ent of diana and owner of the aforementioned property on March 1, 20
Signatur wne 11 name) _ - • Person authorized by duly executed Power of Attomey
� ��� or by IC 6-1.1-12-.07
Full r sident d ss o pplicant Address of authorized person
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