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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
S18ta Fwm 63709 (RS / 4-03)
PrescnDeO by Department of Loral Govemment Finance
Coun Townshi Year
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INSTRUCTIONS: JAN Fpe y�2�O6
To be filed in person or by mail with the County Auditor o) tha county where the propeRy is located. �� 4[u �
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Filing Dates: 1) Real Pioperty: During the 12 months 6e%re May 11 0l fhe year the deduction is to 6e efiective.
2) Mobile Homes assessed under IC 6-1.1=7: Between January 15 and March 2 0/ the year fhe tior�a' ,��,be effective.
See reverse side /or additional instructions and qualifications. GIBSON COUNTY UDI70R
Applicant (own or ntracf buyer - s�tncfion on rse side) �,1J . �
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Taxing Distrid Key number / legal descriplion Record number �
`� O / OOIO �rO`-� Page number
Assessed value of real property as of Mortgage / Contred indebtedness unpaid as of Is the applicant lhe sole legal or equilable
March 1, curtent year March 1, current year owneR ❑ Yes ❑ No
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I( oo, what is his / her exact share of interest? If owned with someone other lhan spouse, indicate with whom.
-ao-c�-/do-aoo. /8/-ao/
If name on record is different than that of applicanl, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Hortie (IC 61.1-�
�me of mortgagee or contrad seller
Address ot mortgagee or contracl seller (number and stieef, city, state, Z
Name of assignee or other owner or holder oi mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Ta�cing Distric[? Has this dedudion been requested on
county in Indiana? property for wrrent yeaR � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amounl of:
20 � 20 �_ 20 20 20 20 20
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Signature County Audflor Date
/ We ceriify under the penalty of pery"ury that the above and foregoing information is true and correct and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Si nalure (owners /ull name) r Person aulhorized by duly executed Power of Attomey
ar by IC 6-1.1-12-.07
Full resident address of a li t Address of authorized person
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