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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' ' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S / Stata Fortn 43709 (R4 / 1401)
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Prexri0e0 Dy Department ot Local Govemment Finan[e
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INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Audilor of the county where the property is locafed. ����� �
Filing Dates: 1 J Real Property: During the 12 months be%�e May 11 0/ the yea� the deduction is to be e c e. �� -�
2) Mo6ile Homes assessed under IC 61.1-7: Behveen January 15 and March 31 0/ the ye he d u rs�to'b�e ct�ve.
See reverse side for additional instiuctions and quali�ca6ons.
MAY 0 2 2003
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Applicant (owner or crontract buyer s e restricUons on revers si , 1 //
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GIBSON COUNTY Al1DITOR
Taxin Dislrid Key number / leg description Record number O�_
.� Q O � / , /� 4(Lbs-� Page number � ��\
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Assessed alue of real properry as of MoAgage / Contrad indebtedness unpaid as of Is the applipnt Ihe sole legal or equitable
March 1, rrent year March 1, current year owne(7 ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned wilh someane other than spouse, indicate with whom.
If name on record is different than thai of applicant, indicate below: Is lhe propeAy in question:
❑ Real Properiy ❑ Modle Home (IC G1.1-�
�ame of mortgagee or conirad seiler
Address of mortgagee or conVad seller (number and streef, city, state, ZI
Name of assignee or other owner or holder of moAgage
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Address of assignee (num6er and st2et, city, state, ZIP code) �
Dces applicant own property in any other If yes, what county? What Taxing Distrid? Has lhis dedudion been requested on
county in Indiana? property for curtent year? 0 Yes� No
COUNTY AUDITOR
Dedudion approved in the amount of:
zo �_ io zo _� 20 �� zo � zo �� zo �_
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Signature County Auditor Date
I/ We certify under ihe penalty of peryury lhat the above and foregoing infortnation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforemenlioned propeRy on March 1, 20
Sign ure (owners l�n�am@) , Person authorized by duly executed Power of Attomey
��, �7 � or by IC 6-1.1-12-.07
Full resident addre s of appliqnt Address of authorized person
3! 7 s� Ui�6 �St t(A�Bs7i¢p7 /,c1 �7639
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