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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
F FOR DEDUCTION FROM ASSESSED VAIUATION Coun Township Year
S / State Fwm 43709 (R5 / 4-03)
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PresaiDed by Department of Locai Govemment Finance
�RUCTIONS: Fi e Ma�
be filed in person or by mail with the County Auditor oJ the county where the propeRy is located. y
Filing Dates: 1) Real PropeRy: Dunng the 12 months 6efore May 11 01 the year fhe deduction is to be e fiv� '
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year he deduc �on is�o—Ge e�ve.
See reverse side for additional instnictions and quali�cafions.
ocr 2 � 2003
Applicant (owner or contract bu r- ee re n i ns o� teverse side) /�� �' ";���c.�11c���
GIBSO�J COUNTV qUDITOR
Taxing District Key number / legal de cription Record number c'1
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�\ r/l���C.X-�-� V��� O O%`� s� O Page number . ��
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? ❑ Yes ❑ No
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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 than that of applicant, indicate below: Is lhe property in question:
❑ Real Property ❑ Mobile Home (IC E1.1-7)
/� Name of mortgagee or contract seller / ^
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�ress of mortgagee or contract seller (number and street, city, s ate, 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 curtent year? ❑ Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
zo zo .5 20 � zo � 20 0 9 zo � zo
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Signature Counry Auditor Date
I! We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
t a resident of Indiana and owner of the aforementioned property on March t, 20
'-n ture (owners full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
� Full resident address of app icant Address of authorized person
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