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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
State Form 43709 (R4 / 70-Ot) , T , � --� � /�
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Prescribed by Department of Lotal Govemment Finance
wsrRUCrioNS: MAY 13 20�� Ma�
To be filed in person or by mail with the County Auditor o/ the county where the propeity is located.
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0l the year the deductio(i�is to 6e e//ective. ///1 I//�
2) Mobile Homes assessed under IC 6-1J-7: Between January 15 and March 3L,qf fhe.yearythe,�d uc6d"n�lsfo be ef/ective.
See reverse side /or additional instructions and qualifica6ons.
�d GIBSON COUNTY AUDITOR I
Applicant (own i or contract buyer- see re 'ctions o verse si ,
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Tauin�trid Key number / legal scription Record number
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_/�,� � O/c..�� O/ �S /0,�� Pagenumber
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Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, wrrent year March 1, cunent year ownert ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of appticant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC G1.1-�
"' me of mortgagee or contract seller
Address of mortgagee or co Iler (number an et, city, state, /
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Name of assignee or other owner or holder of mo ge
Address of assignee (number and street, city, state, ZIP code)
Does applipnt own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for current year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �� 20 a. f 20 20 _� 20 �_ 20 � 20
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Signature County Auditor Date
We ceAify under the penalty of perjury that the above and foregoing information is true and corred and that ihe applicanls was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
ignat wn /s lu name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full resident ad ss of plipnt Address of authorized person
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