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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNES
FOR DEDUCTION FROM ASSESSED VALUATION
Slate Form 43709 (R6 / 5-OG) �
Presuibetl by Depariment of Local Govemment Finance
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INSTRUCTIONS: � L 2 �B-My�
To be filed in person o� by mail wrth the County Auditor o( the county where the property is located. O CT
Filing Dates: i) Real P�operty: Dunng the 12 months 6e%re ,lune 11 of the year lhe deduction is to be eNec6ve.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the ye'�,�dg�s to be elfective.
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See �everse side /or additional instnictions and quallfications. � G�gSON COUNTY AUDIT�R
Applican wner or contract 6uyer - restrictions on reverse side)
Taxing Distrid Key number / legal des 'ption Record number�
� � � ab=i a�=o�- �ro i-oo i. ya, _o Pf38e number �
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, curtent year March 1, current year ownef! ❑ Yes ❑ No
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If no, what is his / her exact share of interest? I( owned wilh someone other than spouse, indicate with whom.
If name on record is difterent than that of applicant, indicate betow: Is lhe property in question:
• ❑ Real Property ❑ Mobile Hm�e QC 61.1-�
me of moRgagee or contract seller
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Address of mortgagee or conVad seller (nu er and street, city, state, ZIP "'
Name of assignee o� other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county7 What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current yeaR � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amounl of:
20 SZ 20 � 9 20 20 20 20 20
1 A
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Signature County Auditor Dale
We certify under the penalry of pe�jury lhat the above and foregoing information is true and corred and that ihe applicants was / were
� resident of Indiana and owner of the aforementioned property on March 1, 20
igna re (owners /ull n me) Person authorized by duly exewted Power of Attomey
or by IC 6-1.1-12-.07
ull e ident address o ap licant Address of authorized person
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