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al� ' STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�i' `= FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
�. �. «. -1, State Fortn 43709 (R6l 5-06) �
� Presaibed by Department of �opl Govemment Finance
INSTRUCTIONS: SEP O 66ii�YJ1'�ric
To be filed in person o� by mail with the County Audito� of the county where lhe p�operty is located. '
Filing Dates: 1) Real P�operty: During the 12 months before June 17 of the year the deduction is to be e���i/� ,� �'
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 2 of the yea� ttle �ction ����j�f/ective.
See reverse side for additional instructions and qualifrcations. GIBSON COUNTY !
Appiicant (owner or contract buyer - see re c6ons n reverse side)
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Taxing Dislrid Key number / legal descnption Record number
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a b' ��'3I�-�y p�-�, 5 Q�-� Page number � y
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Assessed value of real property as of Mortgage / Contracl indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year ownef? ❑ Yes ❑ No
7 600
If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of appiicant, indicate below: Is the property in question:
Real Property ❑ Mobile Hm�e QC 61.1-�
�e of mortgagee or contract seller
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Addrass of mortgagee or contrad seller (number and street, ci . state, ZIP
Name of assignee or other owner or holder of mortgage
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Address of assignee (number and street, city, state, ZIP code) "" • • • • • • � • ... ,
Does a licant own ro e Card i�'Q. � 7� 9
pp p p rty in any other If yes, what county? "' •••••i •.., ction been requested on
county in �ndiana? ��7 C� �rrent yeaf?� Yes❑ No
� 30 � COUNTY AUDITOR
Deduction approved in t amounf of:
20� 20 0 9 20 20 20 20 20
P �°
Signature County Auditor Date
We certify under the penalty of perjury that the above and foregoing information is lrue and corred and thal the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Si tur (owners full na e) Person authorized by duly executed Power of Attorney
k�� �� ���`� orbylC6-1.1-12-.07
Full resident address of applicant Address of authorized person
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