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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
+ �«� ! Siate Fwm 43709 (RS / a-03J �
� Prescribed by Depanment ot Loral Gtivemment Finance
INSTRUCTIONS:
To be filed in person oi by mail with the County Audito� o/ the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 months 6e(ore May 11 of the year the deduction is to be ��gtiv6. 4 ZQO6
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction �s to be effective.
See reverse side for additional instructions and qualificatrons. �7J�� ��
GIBSON CO(/NTY Alin�rn.,
(owner or contract
Taxing Dislrid
Assessed value of real property as of
March 1, curtent year
on reverse
Key �umber / legal description � Record number
' Page number n ^ �
�� y.
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year �-7 ppOa owneR ❑ Yes ❑ No
n
If no, what is his / her exact share of interest? If �wned with someone other than spouse, indicate wilh whom.
�-� -i9-��3-ao .�35a -�a
It name on record is different than that of applicant, indicate below: Is the property in question:
of mortgagee or contrad seller
Address of mortgagee or conirad seller
Name of assignee or other owner or holder of mortgage
of assignee (num6erand st�eet, city, state,
Does applicant own propertv.�.+-^—�-"
counN i�-�^"�
�ra��'er
�� ��........•
�qq�........,
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' Card 1 � �76,C�° /
< �,� zo 0 9
� f P
Signature _ _
city, state, ZIP
code)
❑ Real Property ❑ Mobile Home (IC 61.1-�
�hat county? What Taxing District? I Has this dedudion been requested on
property for curtent year? � Yes 0 No
COUNTY AUDITOR
zo 20
County Auditor
Zo
�
We certify under the penalty of perjury that the above and foregoing information is true and correcl and that the applicants was / were
'esideni of Indiana and owner of the aforementioned property on March 1, 20
0
Person authorized by duiy executed Power of Attorney
or by IC 6-1.1-12-.07
Full re�idelit addre�$ of applicant � � � �- �� �� � IAddress of authorized person