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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S / State Form 43709 (RS / 4-03) . �
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� Presrnbed by Department of locai Govemment Finance �
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INSTRUCTIONS: 3 1 2O6Ne Mark
To be fifed in person or 6y mail with the CounryAUditor of the counry wheie the property is Iocated.�U�'
Filing Dates: 1) Real Property: During the 12 montbs before May 11 of the year the deduction is to be effectiveZ�
2J Mo6ile Homes assessed under IC 6-1J-7: Between January 15 and March 2 o/the ye��e dedil"rtion is t� 6e eNective.
See reverse side (or additional instructions and qual�caUons. G18SON C� NTY A�����
Applican owner or contrac buyer see trictions on rever d
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Taxing islnd ey umber / legal description Rewrd number
/�-�'-//-ooa. �3G/-�ad� -
� _ � Page number
Assessed value oi real property as of Mortgage / Contrad indebtedness unpaid as of Is lhe applipnt t�e sole legal or equitable
March i, current year March 1, cunent year ownef? Q l�es ❑ No
3�b�
If �io, 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 applicanl, indicate below: is r erty in question:
eal Property ❑ Mobile Home QC 61.1-�
•me of moAgagee or conVact seiler
Address of mortgagee or contrad seller (number and street, city, state, ZIP
Name ot assignee or other owner or holder of mortgage
Address of assignee (numberand sheet, city, s[ate, ZIP code)
Does applicant own property in any other If yes, what counry? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for wrrent yeaR� Yes❑ No
/ COUNTY AUDITOR
Deduction approved in t e amounl of:
20 O' 20 �� 20 � 20 20 20 20
1 �
Signature County Auditor Date
We certiy under the penalty of pery"ury that the above and foregoing information is true and corred and that the applicants was / were
resideni of Indiana and owner of the aforementioned property on March 1, 20
S' nature (owners full name) Person authorized by duly executed Power of Atlomey
or by IC 6-1.1-12-.07
ull resident a dr s of applicant Address of authorized person