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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
State Form 43709 (RS / a-03) � �
PrnscnDetl by Department of Local Gtivemmenl Finarka �
INSTRUCTIONS: MAR O � 20(�i e Mark
To be filed in person or by mail with the County Auditor o( the county where fhe property is located.
Filing Dates: 1J Real Property: During the 12 months be%re May 11 of the year the deduction is to 6e e(fectiv
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the`�yt� �'on is to be effective.
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See reverse side Ior additional instnictions and quali�cations. G�gSON COUNIY AUDITOR
Appticant (owner or cont�acf buy r- see restrictions�verse s'
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Taxing District Key number / legal descriptio Record number o 5- b
�')')m Do s-�s 9a -� Page number
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, wrrent year March 1, current year owner? �Yes ❑ No
0 DOD.
Ii 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 than that of applicant, indicate below: Is the property in question:
�eal Property ❑ Mobile Home QC Cr1.1-�
'��ne of mortgagee or conlraIX seller �/
Address of mortgagee or contrad seller (number and sfieet, city, state, ZIP
Name of assignee or other owner or holder of mortgage -
Address of assignee (num6er and st�eet, city, state, ZIP code)
Does applicant own property in any olher If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? propeRy for wrrent year?�] Yes❑ No
COUNTY AUDITOR
Dedudion approved in the amounf of:
zo �(� 2o D 7 20 �L za Q� 20 20 20
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Signature County Auditor Date
�� We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
.sident of Indiana and owner of the aforementioned property on March 1, 20
Signature ( ers full name) Person authorized by duly executed Power of Attomey
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or by IC 6-1.1-12-.07 �
Full resident address applicant Address of authorized person
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