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i,�N } STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
= FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
y State Fartn 43709 (R6 / 5-OG) � � ��
��� Presaibed by Depariment o1 Local Gavemment Fi�nce
INSTRUCTIONS: MAR O % ��O�a,�
To be filed in pe�son o� by mail with the County Auditor o/ the county where the property is located.
Filing Dates: 7) Real Properry: Dunng the 12 months 6e%re ,1une Il of fhe year lhe deduction is to be �re.,�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the ear the�educ�is to be elfective.
GI�SON COUNTY AUDITOR
See �everse side for additional instructions and qualifrcations.
Appl' nt (owner or contract yer - see restrictions on reverse side)
Taxi g Distrid Key number / legal descriplion Record number
a�-�8-i.3-ioi-ooi. 7
�j -L �����,�µi �� � _ �� � Page number n � ( /
/ /L / (O
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, currenf year March t, curtent year ownef? ❑ Yes ❑ No
/,Z D d0 0
If no, what is his / her exad share of interest? Ii owned with someone other lhan spouse, indicate with whom.
If name on record is drfferent than that of applicant, indicate below: Is the property in question:
❑ Real Properly ❑ Mobile Home QC 61.1-�
�e of mortgagee or tract seller
Address of mortgagee or conira elier (number and st2et, city, state, ZIP -
Name of assignee or other owner or holder of mortgage DCa 15'�I' 1�'�. U �
... 7.. 7�'!G
Address of assignee (number and street, city, sfate, ZIP code)
Card i\i�;�„� ; .
...
Dces applicant own property in any other If yes, what county? What T -'-��� °`'� .: . . equested on
county in Indiana? N�„�,,,,,, ._ ❑ Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �� 20 � 20 20 20 20 20
J a
Signature County Auditor Date
We certify under the penalty of peryury lhat the above and foregoing information is true and correcl and that the applicanls was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
Si ature (owners 11 name) Person authorized by duly executed Power of Attomey
� or by IC 6-1.1-12-.07
Ful resident address of appli t Address of authorized person
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