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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S / Stata Fortn 43709 (RS / 4-03) � � � � �� n
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PmsaiDed oy Deparur,ent of Laal Govemment Finance O U
INSTRUCTIONS: .IUL 1 8 ���a,�
To 6e filed in person or by mail with the County Auditor of the county whe2 the property is located.
Filing Dates: 1) Real Property: During the 12 montbs before May 11 of the year the deduction is to be`eBective.��,
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the yeaYr tiie,deduction is to be eflective.
See reverse side Ior additional instructions and qualifications. GIBSON CbUN7v AUtii7pR
orcontractbuyer-
�
Assessed value of real property as of
March 1, current year
If �io, what is his / her exact share of interest?
on
Key number / legal cription Record number
a�-ia-o8- !_ mo�. ��-oa8 ��
O/9' Q����,(fU Pagenumber �U�
Mortgage / Contrect indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, current year owneR ❑ Yes ❑ No
7� j'�Il� � .
Ii owned wilh someone other than spouse, indicate with whom.
If name on rewrd is different than lhat of applicant, indicate below:
�me of mortgagee or contrad seller �/ S
d
Address of mortgagee or contract sefler (number a d 5t2et, city. state, ZIP
Name of assignee or olher owner or holder of mortgage
of assignee (number and street, city, state, ZIP code)
Ooes applicant own property in any olher f If .•.�„ whaf counry? V'
county ir Indiana? �
DeduCtion approved in the amnunt nf:
20 Q� � 20 �_
Q -_i__�'
Signature
Is the pr
❑ Real
� Mobile Home (IC E1.1-�
�, ��
N�rtT"� ,�'�g�
��m� �� �(o-
` requested on
S�'�VLE/D� ��� �DYes❑No
COUNTY AUDITOR
20 _p� 20 � 20
- P --�
County Auditor
20
20
We ceRify under ihe penalty of penurf �hat the ahove and forr.aoino informaGOn is true and corred and that the applicants was / were
resi!ient of�ndiana and owner of thP aforementi ed property on March 1, 20
w
G
Person a��thnrized by duly executed Power of Nttomey
or by IC 6-1.1-72-.07
Itlent address of a�AliEant Address of authorized person
/n � G L
�lY �' �1✓O`r/'$ J�' �/�:�Al!'�/v.