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�ee'-"� # STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
's'�� FOR DEDUCTION FROM ASSESSED VALUATION
�+ State Form 43709 (R6 / 5-06) � '
� Prescdbed �y Departmenl of Loql Govemment Finance
INSTRUCTIONS:
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To be filed in person or by mail with the CountyAuditor of the county where the property'is located. �UL 3 ��UU%
Filing Dates: 1) Real P�operty: Dunng lhe 12 months 6e%re ,lune 17 of the year the deduction is to be ellective.
2) Mobile Homes assessed under IC 6-7. 7-7: Between January 15 and March 2 0l the year the'�r�� effective.
See �everse side for additional instiuctions and quali(ications. G�gSON COUNTY AUDITOR
Applicant (o er r nf2ct yer- see ie�Mdion n reverse side)
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Taxi Disl y number / legal de cription Record number
� �� �a—G�� � �/ ' Page number � �
Assessed value of re roperty as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current yea March 1, current year ownef? ❑ Yes ❑ No
/� `� 7�• C.+�
If no, what is his / her exact share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question: _
❑ R� ^-- y` � QC 61.1-�
�-ne of mortgagee or contract seller Qp.
�. Dra���er ��•p �� _�
Address of mortgagee or contrad seller (number and street, city, state, ZIP ,,
Card ��• ...... . .....
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 Dislrid? Has lhis dedudion been requested on
county in Indiana? property for wrrent year? � YesO No
COUNTY AUDITOR
Deduction approved in fhe amount of:
20 _Q� 20 20 20 20 20 20
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Signature ' County Auditor Date
�' We certify under the penaity of perjury tha[ the above and foregoing information is true and corred and thal lhe applicants was / were
asident of Indiana and owner of the aforementioned property on March 1, 20
Si ture (owners full name) Person authorized by duly executed Power of Attomey
` or by IC 6-1.1-12-.07 -
Full resident address/ of applicant Address of authorized person
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