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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
State Form 43709 (R6 / 5-06)
Presrnbed by Depariment ot Lonl Govemment Finance
INSTRUCTIONS: File Maric
To be filed in person or by mail with the CountyAuditor of the county where the p�operty is located. FEB '/, 2 2��$
Filing Dates: 1) Real Property: Du�ng tlte 12 months before June Il of the year the deduction is to be e(/ective.
2) Mobile Homes assessed under IC 6-1.1 J: Between January 15 and March 2 of the ye�,yre de�tu is to be effective.
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See reverse side lor additional instructions and qualifications. G�gSON COUN7Y AUDITOR
Applicant (own �r ct bu r- see tricti s n reverse �de)
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Taxing Distrid Key number / legal description ecord number
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��o � �{—�O J�3����7�0- � ge number S �
Assessed value of real property as Mortgage / Contrad indebtedness unpaid as of Is the applipnt the sole legal or 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 interesi? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: , Is the property in question:
❑ Real Pmperty ❑ Mobile Home QC 61.1-�
e of moAgagee or contrad seller
Address of mortgagee or conUact seller (number and st2et, aty, st , ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand st2et. city, state, ZIP codel _
Does applicant own property in any ott Dra}��er iVO.. �O�V ... FY. / �� Has this deduc[ion been requested on
counfy in Indiana? property for wrrent year? Q Yes � No
Card NO . ............�......
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Dedudion approved in the amount of:
20� 20 20 20 20 20 20
2 P
Signature County Auditor Date
� We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and thal the applicants was / were
sident of indiana and owner of the aforementioned property on March 1, 20
Signature (owners full name) Person authorized by duly ezecuted Power of Attomey
or by IC 6-1.1-12-.07
F lu Ilesiden ad ress oi applipnt Address of authorized person
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