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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� ! State Fortn 43709 (RS / 4-03)
PrescriDed Oy Department ot Lonl Gtivemment Finar�ce
INSTRUCTIONS: ��� to�2rk.
To be filed in person or by mail with [he County Auditor o/ the county where the property is located. LJ �
Filing Oates: 1) Real Property: Dunng the 12 months be%re May 11 oI the year the deduction is fo be e ec
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of tAe year the deduction is to be e ective.
See reverse side (or additional instructions and qualifrcafions. N� ��$ ZQQS
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Applicant ner rcon ct b ye - ee tnctions on reverse side) GIgSON �
COUN7Y qUD170R
Taxing Dislrid K y number / legal description Record number O�
/ I n , �� rn� _ n/'� �/lj O _ �� Page number � ��
(J{ �.c� l�� d.,CJO C)
Assessed value of real properry as of MoRgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, cunent year owne(? ❑ Yes ❑ No
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If no, what is his / her exad share of interesl? If owned with someone other lhan spouse, indicale with whom.
If name on record is different than that of appiicant, indicate below: Is the property in queslion:
- — :61.1-�
me of mortgagee or contract seller � a 9 9
° Drawer NO. �-�: •••••••••••
Address of mortgagee or contred seller (number and streef, city, state, ZIP Card NO.
........ ...
Name of assignee or other owner or holder of mortgage _ •
Address of assignee (number and streef, city, state, ZIP code)
Does applipnt own property in any other If yes, what county? What Tauing Distrid? Has this dedudion been requested on
county in Indiana? property for current yeaR 0 Yes � No
COUNTY AUDITOR
Dedudion approved in the amouni of:
20 ��7 20 �_ 20 � 20 20 20 20
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Signature County Auditor Date
� We certify under the penalry of perjury that the above and foregoing information is true and corred and that the applicants was / were
a resident of Indiana and owner of lhe aforementioned property on March 1, 20
Signature (owners full name) Person authorized by duly executed Power oi Attomey
�� ��� or by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person
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