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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�> ��� / State Form 43709 �RS / 4-03)
� PrascriDed by Department ol Local Govemmem Fina�xe
INSTRUCTIONS:
Coun Township Year
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JUN �'�9"�J�`6
To be filed in person or 6y mail with the CountyAuditor o/the county where the property is located.
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Filing Dates: 1) Real Property: During the 12 montns before May 11 oI the year the deduction is to be eflective.
2) Mo6ile Homes assessed underlC 6-1.1-7: Between January 15 and March 2 of the year the deduction"is.fo be effective.
See reverse side for additional instnictions and qualifications. G J
GIBSON COUNTY AI�DITOR
Applicant (owner or contiact buyer- see iestrictions on reverse side)
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Tauing District Key number / legal description Rewrd number
� � _ Page number � h
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant (h�sole legal or equitable
March 1, current year March 1, current year owneR f�Y�s' ❑ No
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Ii ,io, what is his / her exact share of interest? f 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:
Properiy ❑ Mobile Horne QC 6-1.1-�
�me of mortgagee or contrad seller
Address o ortgagee or coniract seller (number and street, city, state, ZIP
Name of assignee or olher owner or holder of mortgage
Address of assignee (num6er and street, city, state. ZIP code) __
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Does applicant own property in any olher tf ves. what county? What Ta. ��`�"'- sted on
county in Indiana? /-�/� 1}� , / �s❑ No
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COUNTY AUDITOF
Deducfion approved in the amount of:
20 i� 201j$_ 20 �q_ 20 20 20 20
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Signature County Auditor Date
' We certify under the penalty of perjury that the above and foregoing information is irue and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signatur owners (ull name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-72-.07
Fu r ident address of applicant Address of authorized person
E. ��� %.s �.ND 76