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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Stata Fwm 63709 (R514-03)
PrescnDed by Department of Local Gtivemment Finance
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INSTRUCTIONS: Fil nM�a��c�
To 6e filed in person or 6y mail with the County Auditor of the county where the property is located. St � 1$�"""
Filing Dates: 1) Real Property: During the 12 months betore May 11 0/ the year the deduction is fo be elfective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of tA ear the de uc �s to e ctive.
See reverse side for additional instructions and qualiTcations. /�Z�"`"- "� "`' Y FUDITOR
GIBSON COU
Applicant (owner or contract buyer- see restrictions on ieverse side)
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Taxing Dislrid number / legal description Record number 1
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P Page number C
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Assessed value of real property as of Morlgage / Contract indebtedness unpaid as of Is the applica t the soie legal or equitable
March 1, current year March 1, current year owne(? �es ❑ 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, indicate below: Is lhe property in question:
--- eal PropeAy ❑ Mobile Horrie QC &1.1-�
�me of mortgagee or contraIX seller C �� ��� 7-eQ�/, e2s. C�
Address of mortgagee or contrad seller (num, DYa�VCC N� �� •
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Name of assignee or other owner or holder of i Card NO. •• �
Address of assignee (number and street, city,
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Does applicant own propeRy in any other If yes, what county? What Tauing District? Has this deduction been requested on
county in indiana? property for wrrent year? [� Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
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Signature County Auditor Date
�'/ We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of lhe aforementioned property on March 1, 20
Signatur (owners full name) Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Fu esi ent address of applipnt Address of authorized person
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