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�'�- � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'i' = FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� Stale Fortn 43709 (R6 / 5-OG) � �
�� PreSCnbed by Department of Loral Govemmenl Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor o/ the county whe�e the property is located. �UN 1 � ZQQ�
Filing Dates: 1J Real Property: During the 12 months before ,lune Il of the year the deduction is to be effective.
2) Mobile Homes assessed unde� lC 6-1. iJ: Between January 15 and March 2 0( [he yea� tha.dQr,iNction�s� el%ctive.
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See reverse side for additional instrucfions and qualifications.
GIBSON COUNTY AUDITOR
Applicant (owner or contract buyer - see restrictions on ieverse side)
Tauing Distrid
Assessed value of real property as of
March 1, current year
Key number! legal description � Record number
. . ���=ba$ �
Page number
-1 -b - •6 ( 3
Mortgage / Contrad indebtedness unpaid as of Is the applicaru the sole legal or equitable
March 1, current year owneR ��rties ❑ No
�
If�no, what is his / her exad share of interest?
If name on record is different than that of applicant, indicate below:
of
Address of
or contrad selter
a ., � .>_ 1 ) . , .
If owned with someone other ihan spouse, indicate with whom.
or conVad seller (number and sfreet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st�eet, city, state, ZIP code)
Does applicant own property in any
county in Indiana?
approved in the amount of:
20 � I 20 �_
P �
Signature
If yes, what counry?
c
20 D`T
P
County Auditor
Is- the property in question:
�.Real Property ❑ Mobife Home QC fr1.
What Ta�cing Distrid? Has this dedudion been requested on
property for wrrent year?� Yes❑ No
ll►-a«�cr NO.�.�. �..�.�,.6%
C�1'(1 ��� . ...................
Date
20
We ceAify under the penalty of perjury that the above and foregoing information is true and corred and that ihe applicants was / were
esidenl of Indiana and owner of the aforementioned property on March 1, 20
name)
Person authorized by duty executed Power of Attorney
or by IC 6-1.1-12-.07
Address of authorized person
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