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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fartn 43709 (RS / 4-03)
PresaiDetl by Department ol Laal Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail witA the County Audifor o! the counry whe2 the property is located.
Filing Dafes: 1) Real Property: During the 12 months be%re May 11 of fhe year the deduction rs to be eHective. AP R 2 i 20�4
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year th deduction is to be eRective.
See reverse side for additional instn�ctions and qual�cations. �
° GI9SON COU� i Y AUDITC' ,
Applicant (o r or conjract buyer- see iestrictipns on reverse side)
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Taxing Disiri Key number / legal description Record number
V,� O�- b 4a �D -cap Page number � B'�
Assessed value oi real property as of Mortgage / Contrad indebtedness unpaid as of is the applicant the sole legal or equitable
Marcfi 1, wrrent year March 1, current year ownef? ❑ Yes ❑ No
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If no, what is his / her exact share ot 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:
❑ Real PropeAy ❑ Mobife Home (IC 61.1-�
�Vame of mortgagee or contract selier Q
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Address of moRgagee or contracl seller (number and street, city, sfate, ZIP
Name of assignee or olher owner or holder of mortgage
Address of assignee (numberand street, city, state, ZlPcode)
Does applicant own property in any other If yes, what county? VJhat Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current year? Q Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 Q(� 20 � 20 8� 20 � 20 20
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Signature Counry Auditor Date
/ We certify under the penalty of perjury at t bo d or ing information is true and correct and that the applicants was / were
resident of Indiana and owner of the af�ne����arch 1, 20
ignature (owRers full name) I Person authorized by duly executed Power of Attomey
��� (,�� or by IC 6-1.1-12-.07
Ful resident address of applicant Address of authorized person
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