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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
State Form 43709 (R6 / 5-06) � � � � - '
Prescribed by Department of Lonl Govemment Finarxe
INSTRUCTIONS: 4 ZFII� MaAc
To be (iled in pe�son or by mail with the County Audifo� of the counfy where the p�ope�ty is located. ,f AN 1 ���
Filing Dates: 1) Real P�operty: Dunng the 12 months be%m June Il of the year the deduction is to be eflecfive.
2J Mo6i/e Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the ye�pFq�� is to be eHective.
See reverse srde for additional instiuctions and qualifrcations. GIBSON COUNTY AUDITOR
Applicant (owne� or contract b - see restrictions on erse si�
Il./
Taxing Disirid Key nu er / legal description - Record number O
"') � � ^� -� Page number r p O
ar `� J 7
Assessed value of real property as of MoAgage / Conlrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year ' ownef� ❑ Yes � No -
If no, what is his / her exact share of interesl? If owned with someone otherthan spouse, indicate wilh whom.
If name on record is difterent than that of applicant, indicate below: Is the property in question:
O Real Property ❑ Mobile Home pC E1.1-�
�me of mortgagee or contrad seller
Address of mortgagee or conVad seller (n ber and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and stieet, city; state, ZIP code)
Does applicant own property in any other Ii yes, what county? What Tauing Distrid? Has lhis dedudion been requested on
county in Indiana? property for wrrent yeaf? � Yes� No
COUNTY AUDITOR
Dedudion approved in the amount of:
20 �Q� 20 � 20 20 20 20 20
P �
Signature County Auditor Date
�� We certify under the penalty of perjury thal the above and foregoing information is true and corred and that the applicants was / were
�sident of Indiana and owner of the aforementioned propeRy on March 7, 20
Signalure (owners /ull name) Person authorized by duty executed Power of Attomey
� ��� or by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person