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;` '" � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
��i�. FOR DEDUCTION FROM ASSESSED VALUATION
i+ S�ate Form 43709 (R6 / 5�06) � ' - , '
� Presaibed by Department of Lopl Govemment Finance
Count Township Year
INSTRUCTIONS: Fite Mark
To be fi/ed in pe�son or by mail with the County Auditor of the county whe�e the property is located. NO V 2 20G7
Filing Dates: 1) Real Properfy: During the 12 months befo2 ,lune 11 0/ the year the deduction is to be eff ive.
. 2) Mobile Homes assessed unde� lC 6-1.1 J: Between January 15 and March 2 of the year �c,�ij��js to be eflective.
See �everse srde foi additional instruclions and qualificalions. G�BSON COUNTY q�jpITOR
Applicant (owne conhact buyer- see rest 'cti s on reverse side)
Taxing Distrid Key number / leg description Record number
Page number
� � a�-�9-i8�o�-000.s,�i.oa,�
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the appli�
March 1, wrtent year March 1, current year ownef?
I � _ _ �
If no, what is his / her exact share of interest7
name on record is different than lhat
of mortgagee or contraIX seller
indicate below:
I�
t the sole legal or equitable
❑ Yes ❑ No
owned with someone other than spouse, indicate with whom.
❑ Real Properry O Mobile Horne pC 61.
' �N t'>
Address oi mortgagee or contrad seller (number and street, city, state, ZIP
�_ -
—�
Name of assignee or other owner or holder of mortgage Dra�S'e1' I�'� � 7
Address of assignee (number and st�eet, city, state, ZIP code) Card N0. , !�O� �
.......
Does applicant own property in any other If yes, what county? Wh; Q� .t.� ���� �• � auested on
county in Indiana? �i]�o..� �� ] Yes� No
Deduclion approved in the amount of:
20 � 20 20
(
Signature
COUNTY AUDITOR
20
County Auditor
�
20
20
We certiy under the penalty of peryury that the above and foregoing information is true and corred and that lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
�na%t� (ow s full name) Person authorized by duly executed Power of Attomey
�iC _. , %v, __� or by IC 6-1.1-12-.07
Full resfdent address of ap�i ant V IAddress of authorized person
7°s,l�� ei,e,-L 11,.., C'_„� !.!a_ ._t �.