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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Slate Fortn 43709 (R4 / 70-01)
PrewibeA by Department of Local Govemment Finance
Coun Township Year
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INSTRUCTIONS: h t� O,� F,j1e,Mark
To be filed in person or by mail with the County Auditor of the county whe2 the property is located. LUUJ
Filing Dates: 1) Real Property: During the 12 months be%�e May 71 0/ the year the deduction is to be effective. �
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 o7�/,the year the�dedvction islo b�e/%ctive.
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See reverse side for additional instiuctions and quali�ca6ons. GBSON COUPT'r �:UDI70Y.
Applicant (owner or t c buyer se res c n on reverse �
Taxing District Key number / legal description Record number �
�/�/� OD/�)D �'7� �-�\ Page number � � 2
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Assessed vatue of real properry as of Mortg�Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year Mar rrent year 7�a�j� owneR ❑ Yes ❑ No
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If no, what is his / her exacl share of interest? If owned with someone other lhan spouse, indicate wilh whom.
�- o' -�O�-U�O. $70 -ao/
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home pC 61.1-�
�3me of mortgagee or contract seller
Address of mortgagee or contrad seller (number and sfreet, city, state, Z!P
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP code)
Does applipnt own propeRy in any other If yes, what wunty? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for wrrent yean 0 Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
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Signature County Auditor Date
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�/ We certify under lhe penalty of perjury that the above and foregoing information is true and correct and thal lhe applicants was / were
resident ot Indiana and owner of the aforementioned property on March 1, 20
Si ure wners a Person authorized by duly execuled Power of Attomey
` or by IC 6-1.1-12-.W
ull resi nt addres oi applipnt Address of authorized person
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