Mortgage_Pollocka` * �
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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Stale Form 43709 (R6 / 5-06)
Presaibed by Depariment of Lonl Govemment Finance
Coun Township Year
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$ 1 �J 1LJ JL/
INSTRUCTIONS: OCT G��i [uu6
To be filed in person o� by mail with the County Auditor of the county whe�e the property is located.
Filing Dates: 1J Rea( Property: Dunng the 12 months befo2 ,lune I1 0/ the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the yea� tlie deduction'is'to be effective.
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See reverse side for additional instructions and qualifications. pIBSON CGUNTY AUDITOR
Appiicant (ownerorcontracPbu er- see resMc6ons o verse 'de)
Taxing Distrid Key number / legal description Record number �
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1�. _�I'. . O� ' 0���_� Page number �
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Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applipnt e sole legal equitable
March 1, curtent year March 1, wrrent year owneR ❑ Yes ❑ No
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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 different than that of applicant, indicate below: Is lhe property in question:
❑ Real Property ❑ Mobile Hmie QC 61.1-�
me oi mortgagee or contrad seller �
Address of mortgagee or contrad seller (number and stieet, city, state, Z/P
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, sfafe, ZIP code)
Does applicant own properfy in any other If yes, what counry? What Taxing Dislrid? Has this deduction been requested on
county in Indiana? property for wrrent year?0 Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
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Signature County Auditor Date
We ce' under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
resi t of Indiana and owner of the aforementioned property on March 1, 20
ture w ers full name) Person authorized by duly executed Power of Atlomey
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ul ident ddress of applipnt Address of authorized person
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