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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�s ` J State Fwm 43709 (RS I 4-03)
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� Pmscribed Ey Department ot Local Govemment Finance
INSTRUCTIONS: ,–� -i n - File Mark, – -
To be filed in person or by mail with the County Auditor o/ the county whe�e the property is located. Ei..d ti rkIf � cq, �i`I
Filing Dates: i) Real Property: Dunng the 12 months before May 11 of the year the deduction is fo be.Eeffecti�v1e.1L�' '� }Ly
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 of the year the deduction is to be eflecfive.
See reverse side Ior additional instructions and quali�cations. A�� �' 2�03
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Applicanl( ,rorcontracfbuyer-seerestnctionspnrevers side �"""""�``f�'tl��-�^^-t�—'
GIBSON CGi7\" t qU7'TC'� :
Taxing Dis ict Key number / legal description Record number �
� Page number ` �
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Assessed value of real property as of MoAgage / ContraG mdebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, currenf year March 1, curtent year owneR ❑ Yes ❑ No
Ii no, whal is his / her exad share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than thai of applicant, indicate below: is the property in question:
❑ Real R'operty ❑ Mobile Home (IC 61.1-�
�e of moAgagee or contrad seiler
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Address of mortgagee or conlract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
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Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
wunty in Indiana? property for current year?� Yes❑ No
COUNTY AUDITOR
Dedudion approved in the amount of:
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Signature County Auddor Date
We certify under lhe penalty of perjury lhat the above and foregoing information is true and correct and lhal lhe appiicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
nat re (owners (ull name) Person authorized by duty executed Power of Attorney
or by IC 6-1.1-12-.07
uti resident address of applicant y�6,� � Address of authorized person
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