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�� �� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
s��); FOR DEDUCTION FROM ASSESSED VALUATION
'�fJ SUte Fwm 43709 (R6I5-O6)
��� Presaibed by Department of Local Gwemment Finarxe
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INSTRUCTIONS:
Count Township Year
F'I ark
To be filed in person o� by mail with the County Auditor ol the county where the property is located. MAR 1 4�"""
Filing Dates: 1J Real P�operty: Dunng the 12 months before ,lune Il of the year fhe deduction is to be e(fective.
2) Mobile Homes assessed unde� lC 6-1.1J: Between January 15 and March 2 of the yeaY�,dp,fiyq,$'� to be eflective.
See �everse side for additional instruclions and qualifications. GIBSON COUNTY AUDITOR
Applicant (owne� or con c bu - see cti on re rs de)
Taxing Dislrid Key number / legal description Record number O�
a(O��—�� ��7—(.J�/.� ��umber /�7y
Assessed value of real property of Mortgage / ContraIX indebtedness unpaid as of is the applicant the sole legal or equitable
March 1, curcent year March 1 nent year owneR ❑ Yes ❑ No
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If no, what is his / her exad share of interesl? If owned with someone other than spouse, indicate with whom.
If name on record is different ihan that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Horrie QC 61.1-�
�e of mortgagee or contrad seiler / n C��J) .
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Address of mortgagee or contrad seller (number a street, city. state, ZIP
Name of assignee or olher owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in an c Li. � Has this dedudion been re uested on
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county in Indiana? ll��1N'�I' \ O••� . property for current year?C� YesO No
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� Card \O••••� ....
Deduction approved in the amount o� ��
20 �_ 20 �� 20 20 20 20 20
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Signature County Auditor Date
We certify under the penalty of perjury thal lhe above and foregoing information is true and corred and that the applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
ignature ners (ull ame Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
F�esident ress a licant Address of authorized person
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