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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
S�ate Fofm 43709 (R4 / 70.01)
Prescribed by Department oi Lo�al Govemment Finance
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INSTRUCTIONS: File Mark
To 6e filed in person or 6y mail with the County Auditor ol the co�nty where the property is located. MAK 2 i 2�03
Filing Dates: 1) Real Property: Dunng fhe 12 months be%re May 11 0/ the year the deduction is to be effective.
2) Mobile Homes assessed wder IC 6-1.1-7: Between January 15 and March 31 0/ year the dedu�chon is tobe �e/i�ective.
See reverse side (or addifional instructions and qualifications. �-'--��-�J°,'��-��--C
' GIBSON COUNTY AllDt?OR 1
Applicant (ovmer or contract bu r see �estrictions n versq sid )
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Taxin Distrid Key number / legal descriplion Record n er ��
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or e uitable
March 1, curtent 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 lhan spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Modle Home QC G1.1-�
�me of mortgagee or contrad seller
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Address of mortgagee or contrad seller (number and st2et, city, state, ZI
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st�eet, city, state, ZIP code)
Dces applipnt own property in any other If yes, what counry? What Taxing Distrid? Has this deduction been requested on
counfy in Indiana? property for curtent year? Q Yes� No
COUNTY AUDITOR
DeducGon approved in the amount of:
20 � 20 O 20 _� 20 20 � 20 �_ 20 �_
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Signature County Auditor Date
I/ We certiy under the penalty of perjury that the above and foregoing infortnation is true and corred and lhat the applicants was / were
resident of Indiana and owner of lhe aforementioned property on March 1, 20
Signalure (owners full name) Person authorized by duly executed Power of Attomey
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II resident address of a pli nt Address of authorized person