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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Slate Fofm 43709 (Rd / 10.01)
PrescribeC by Departnent of Local Govemment Pinance
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INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor o7 the county whe2 the property is located. Q � T 1(j Z0�2
Filing Dates: 1) Real Property: During the 12 months 6e7ore May 71 0l the year the deduction is to be ef/ective.
2) Mobile Homes assessed under IC 6-1. 7-7: Behveen January 15 and March 31 / he year th deduction is to b effective.
See reverse side Ior additional instiuctions and qualificafions. --� v���-
GIBSON COU`i i'! AUOITOR
Applicant (ow orcontract buyer- se rest ' ns o�ide)
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Taxing Distrid Key number / legal description Record number
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Assessed value of real property as of Mortgage / ContraG indebtedness unpaid as of Is lhe applica t the sole legal or equitable
March 1, current year March 1, current year owner? ❑ Yes ❑ No
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 ihan that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Hane (IC 61.1-�
me of mortgagee or contrad seller
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Address o( mortgagee or contrad se�ler (number and street, cify, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for current year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount ot:
20 OT? 20 20 � 20 20 20 � 20�� O�j
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Signature County Auditor Date
We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
r ident of Indiana and owner of the aforementioned property on March 1, 20
' ature (owner's full name) � Person authurized by du�y executed Power of Attomey
or by IC 6-1.1-12-.07
u esident address of a li n Address of authorized person
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