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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
s FOR DEDUCTION FROM ASSESSED VALUATION
� State Form 43709 (R71 / 609)
- �` � Presai6ed by DePartment af Lmal Govemment Frwce
Fie� a
INSTRUCT70NS:
To 6e filed in person w by mail with the CountyAuditor o� Counry Rewrder o/ the county where Ihe property is located. F� �� �n1'�
Fiting Dates: 1 J Real Property: Must file dunng the yea� for which the deduction is sought. O C 2� ZI�Lnty Audhw
2) Mobde / Manufactured Homes rrot assessed as Real Property Must file dunng the fwelve (72) months
6etore March 31 0( each year the deduction is sought. C ��unry Recorder
See reverse side r eddi[ional instructions antl qualifica[ions. v
no�m( convadb e e^ ��s �es�+e� � GIBSON COUNTY AUDITOR
�if—�
T' Key ber / I al desaiption Rem number P e nu bel
- 03�0� oo . /-Do? �G�� S'
vdlue d real of Mortgage! Contract 4Me6teCness unpaid as ot Mortgage / Coniract inEebtedness unpaid as ot Is �he applkant M sde
t, mrent year / Mard� 7, artem year date of ap legal w equitade ownrll
l � � ❑ Yes ❑ No
If ro, what Is ha / her eud share of inte.2st? 1/ wmed with sameane other ihan spouse, i�Nate with whom
tt�nie m remG a CiHerent fhan Nat o( aPP�t cMUate Gelmr. h tlie property in Gues6on: MnuaM Assessed
eal RoPeAY ❑ Armually Pssessed .
MobileFiome ICGt.t-7)
Name W rtprtgagee a mntract seqer
Address ot mort9a9ce «cantracl u4e and sbee; cdy, state, arrd P e)
Name ol assignee w other owner or hdder of mortgaga
A4Cmss ol assgnee (number aM slreeL my, sfate, and LP code) n�
//— ^ Q V
Dces applirent own propeny in any oNer If yes. wlw[ countyt ' Wtut Taring DisGict7 Has Ihis Cetlurtim Eeen reQUesteO on prapnny
munry in IrM'oria? ❑ Y2s ❑ No � artent yea(1 ❑ No
❑ Yes
COUNTVAU�ROR
DeducCm approved'ui the amwnt of.
Zp _ 20 _ 2b _ 20 _ 20 _ 20 20 _
SignaMe of Counry AuEitor Counry Date (rtcMh. daY• N�A
_ _ — ��'
I/ We cert'rfy under Ne penalty of perjury that Ihe above aM foregoing infortnalion is W e and cortec I
owner I contracl buyer oi the aforementioned property on date applicabon is filed. •
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�Fu0 � ent address of app t(num r and t crry. te, aM ZIP wUe r 3 O� I
i �s. ��o s Z�39 c���� �o . .....................
Pe�.,on author@ed Oy duly ezecuted Power of Attomey or by IC 61.1-12-0.7 I ii �1 �(l7� .� �
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AdEress of auUiw'ved persrn (numDer aral wee; ctiy, state, aM LP code) . �•