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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Townshi Year
ti / State Fwm 43709 (R5 / 4-03)
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� PrasaiDetl Ey Department of lOCal Govemment Finance 4 � � (� ,� ��
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INSTRUCTIONS: �ULFiI�e M�ar�003
To be filed in person or by mail with the County Auditor of the county where the property is located.
Fi/ing Oates: 1) Real PropeKy: During the 12 months be%re May 11 0/ the year the deduction is to be f�ective. �
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the yeai t�U�� to be eflective.
See reverse side for additional instructions and qualifications. GIBSON COUN7v AUDITOR I
Appticant o ner or cont t buyer - se strictio on re rse side)
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Taxing istrid Key number / legal description Record number� 2
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�j /n��,�y ) D jG/_ �/���� Page number ///�
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Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, wrrent year owneR ❑ Yes ❑ No
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 diHerent lhan thal of applicant, indicale below: Is the property in question:
❑ Real Property ❑ Modle Home QC 61.1-�
�me of mortgagee or contraIX seller � �
Address of mortgagee or conlrad seller (nu ber and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st2et, city, state, ZIP code)
Does applicant own property in any other If yes, what county? Wh; ��� � ,s� ested on
county in Indiana? Drawer NO ................ � YesO No
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CardNO . .....................
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Deduction approved in the amount of:
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20 �j� 20 n.� 20 20 �7 20 �� 20 Q`� 20
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ignature County Auditor Date
�'/ We certiry under the penalty of peryury lhat the above and foregoing infortnation is true and correct and ihat lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Si natu (owners full name) Person authorized by duly executed Power of Attomey
��Q or by IC 6-1.1-12-.07
Fuil resident address of applicant Address of authorized person
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