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e`n��.t STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
-' = FOR DEDUCTION FROM ASSESSED VALUATION Coum Township Year
`�� � Sfate Fortn 43709 (R3 / 10.00)
Prescribed Dy State Boartl of Tar Comrttlssioners �
Fite Mark
InsWctions for filing: � E � 0 4 200�
To be filed in person or by mail wRh the County Auditor of4he county where the property is •
located during the 12 months before May 11 of the year the deduction is to be effective. Se
reverse side for additional instructions and qualifications.
GIBSON CO(JN7Y AI�DITOR
Appiicant (own o contract buy - se�restncti . s on rnverse side) � ,
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Taxing Distrid Key n b/ legai descriplion Re mber �/_
�/� � / � � _ d /� Page number R
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Assessed value of real property as of Mortgage / Contrac indebtedness unpaid as of Is the appiicant the.sole legal or equitable .
March 1, curtent year March 1, current 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, indirate below:
of mortgagee or contract selier ��
Address of mortgagee or contract seller (number and st et, city, state, ZIP
Name of assignee or ather owner or holder of mortgage
Address of assignee (number and street, city, state. ZIP code)
Does applicant own real property in any If yes, what county? What Taxing Distrid? Has this deduction been requested on
other county in Indiana? property for current year? � Yes❑ No
COUNTY AUDITOR
Dedudion approved in the amount of:
20 �� 20 � 200 20 20 6(� 20 �z 20 n�9 O`t
5 ��-,�,�a� �' � � P � .P
Signature Counry Auditor Date
e certify under the penalry of perjury that the above and foregoing information is true and corred and that the applicants was / were
;ident of indiana and owner of the aforementioned property on March 1, 20
Sign tur ners full n e) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full re ent address of appli nt Address of authorized person
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