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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Court `��Q '���-1}'
• FOR DEDUCTION FROM ASSESSED VALUATION ). ?� '� "
t" State Form 43709(R11/609)
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Prescribed by Department of lid Government Finance • .. i
INSTRUCTIONS:
F. •-filed with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. •_ •i
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought I, tviWI tnn.t \,11 t OR
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months ��N
before March 31 of each year the deduction is sought. GIBBON 'Ctiunry Recorder
See reverse side for additional instructions and qualifications.
Ag nt(owner or conbali buyer-see on sire)
Tab Key / "7(X° Record number Page nu
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Ma vahs property as of Mortgal, /C Contract Indebtedness unpaid as of dMortgag/ -..indebtedness unpaid as of �app1 nI the sole
�� , COO ❑ Yes ❑ No
If no,what Is his I her exact share of interest? If owned with someone other spouse,indicate with Whom
If name on record is different than that of applicant,indicate below: Is property in question:Annually Assessed
iyJ Real Property ❑Annua(IyAsessed
/ Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller (�, •-
•
`d�..1 / L/ i" ',A/r_ . r . /t V t - 0
Address of mortgagee or contract seller(number and.•,.•f,coy,state,a • /P....•) ' ,
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city:state,and LP code
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Does applicant own property in any other If yes,what county? What Taxing U? Has this deduction been requested on property
county in Indiana? ❑ Yes ID No current Yeas ❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 _ ' �: I �F``�' , -�
Signature of County Auditor County �/. ✓ ('
I/We certrfy under the penalty of perjury that the above and foregoing information is t 13 _ 159
aria and
owner/contract buyer of the aforementioned property on date application is filed.
/, Signature(owner's i name) .. ..
/�/Jl .0 IS . • �.,A l
Full resident address o•:ppficant(number and street,dy,state,and ZIP code)
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Person authorized by duty executed Power of Attorney or by I 61.1-12-0.7 Date(month,day,year)
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Address of authorised person (number and street,city,state,and ZIP code) - \\`'p`