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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S µ� / Siate Fortn d3709 (RS / 4-03)
� PrescriDed by Departmem of Local Govemment Finance
INSTRUCTIONS: O C T], 4�Ma�
To be filed in person or by mail with the Counry Auditor ot the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months 6efore May 11 of the year the deductiori 's to 6e eflective��
2) Mobile Homes assessed under IC 6-1.1•7: Between January 15 and March r�aPtbe,y_e r e d ction i9 to e effective.
See reverse side /or additional instroctions and qualifrcations. GIaSON COUN; v q�ip�TOR
Applicant(ownerorcont cfbuy r-see strict�onrev rse 'C2) . ,
�� �
Ta�cing Distrid Key number legal description Record number Q
�� /� p� �r Q' � � � �/f� ^ /1 Page number � � �
/ V'! '�'v l.�
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant e sole legal or equitable
March 1, current year March 1, wrrent year ownef? ❑ Yes ❑ No
�.�Go00
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is diNerenl lhan that of applicant, indicale below: is the property in question:
❑ Real Property' ❑ Mobile Home (IC 61.1-�
�ame of mortgagee or contrad seller ��
Address ot mortgagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of morigage
Address of assignee (number and st�eet, city, state, ZIP code)
Does applicant own property in any other If yes, what wunty? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for wrrent yeaf? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 Q',� 20 20 �� 20 �� 20 � 20
� P
Signalure County Auditor Date
�I/ We certify under the penalty of perjury thal the above and foregoing information is true and corred and lhal lhe applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
Sig�(owners Iull name) . Person authorized by duly executed Power of Attomey
or by IC 6-7.1-12-.07
rull resi ent address of applicant Address of authorized person
.�a� se. ' �,,.