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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
1 M� / State Fwm 43709 (R5 / 4-03)
PrescnDetl Dy DepaRment of Loral Govemment Finance � ��
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INSTRUCTIONS: p File Mark
To be filed in person or 6y mail wfth the CountyAuditor of the counry where [he properFry'is�locat���
Filing Dates: 1) Real Property: During the 12 mon[hs betore May 11 of the year the deduction is to be eflective.
2) Mobile Homes assessed under IC 6-1:1-7: Between January 15 and Ma�ch'2 of the year the deduction is to 6e e8ective.
See reverse side for additional instructions and ualifications �✓r���`�
Q GIBSON .,
Applicant (owner or con ct buye� - see restrictions on reverse sid •
Taxing Disiri Key number / legal description Record number �
�r`�i� /�O � � �Q �_ ^„ � Page number ,.
lS.ir (J O CJCJ
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, cunent year owne(? ❑ Yes ❑ No
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If no, what is his / her exact share of interesl? If owned with someone olher lhan spouse, indicate with whom.
If name on recard is diHerent than that of applicant, indicate below: Is the property in question:
❑ Reai Property ❑ Mobile Home (IC 61.1-�
�me of mortgagee or contract seller
.53
Address of moRgagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current yeai'?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amounl of:
zo � zo 0�( _ zo � zo o s zo �_ zo zo
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Signature County Auditor Date
�/ We certify under the penalty of perjury that the above and foregoing informalion is true and corred and that lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
' n fure ( wner full name) Person authorized by duty execuled Power of Attomey
or by IC 6-1.1-12-.07
Full esident addres of a lipnt Address of authorized person
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