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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�. -�w� � ♦ State Form 63709 (RS / 4-03) \
� Prescd�ed by Department of Local Gtivemment Finance ^L\ Q
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INSTRUCTIONS: �O
To be filed in person or by mail with the CountyAUditor of [he county where the property is located. � Q(UU�
Filing Dates: 1) Real Property: During the 12 months 6efore May 11 of the year the deduction is to 6e effecti .
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ t/he year fhe d/eduction is to be ective.
See reverse side for additional instructions and qualifications. ����-,( J����
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GIBSON COUNiY AUDI70R
Applicant (ownerorcontra t bu r- see restrictions on re erse i)
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Taxin Distrid Key num er / legal d ption Record number
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Assessed value of real pr erty as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, nt year owner? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone oiher ihan spouse, indicate with whom.
If name on record is different lhan ihat of applicant, indicate below: Is the property in quesiion:
� ' ❑ Real Pmperty ❑ Mobile Home (IC G1.1-�
�3me of mortgagee or contrad seller -- "-- -
Drawer NO. � � — �: � � `�
Address of mortgagee or contrect selier (number and stree , ity, state, ••••• ••••..
Name of assignee or other owner or holder of mortgage Card NO . .....................
Address of assignee (number and street, city, state, ZIP code)
Does appiicant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
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Signalure County Audifor Date
�/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
; resident of Indiana and owner of the atorementioned property on March 1, 20
ignature (owners full name) Person authorized by duly executed Power of Attomey
a r l_(�� _, � or by IC 6-1.1-12-.07
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Full resident address of applicant Address of authorized person
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