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STATEMENT MORTGAGE OR CONTRACT INDEBTEDNESS BTEDNESS Cou hip I Year
�„:_ FOR DEDU CTIO N F ROM AS SES SED VALUATION
S.-
State Form 43709(R11/6-09) F LE il)
Prescribed by Department of Local Government Finance
File
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the properly is located. j re L V qwth
1 3
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought 0 County Auditor
2) Mobile/Manufactured Homes not accassed as Real Property Must file during the twelve(12)months
before March 31 of each year the deduction is sought - ,) , J ., - -'•• •er
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See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR
Ap (owner or contract buyer tee on reverse side)
L ' Q0 Q. 7114—ctaZt. ,rte
Taxing District f Key number/legal description Record number Page number
24, - ) 1 - ( 7 - 30o - 003, gr / - o .1 / 2.0 ( 3 3 /01
Ass ssed I of real of Mortgage/Contra indebtedness unpaid as of Mortgage/Contract Indebtedness unpaid as of Is the applicant the sole
March 1,tarrart year Mardi 1,amrtent year date of application legal or equitable owner?
(- 5 0 o Dyes 1:1 NO
If no.what is his/her exact share of interest? r If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below Is the property in question:Annually Assessed
❑Real Property ❑ArnuayAssessed
. . Mobile Home(IC 6-l1-7).
Name of mortgagee or contact seller
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
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Add of assignee(number and street city,state,and ZIP code) all 13
5".&_) I 1 _ 3 - 11 ,15 A- C- Drawer NO
Does applicant own property in any other If yes,what county? - What Taxing Distric
county in Indiana? El / /2 •
Yes ❑ No '!V„
Card NO.
COUNTY AUDITOR (In 501 tt.
Deduction approved in the amount of:
20 20 20 20 20 20 20
Sig of County Auditor x • County Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
.„Signature(owne name) Date(month,day,yeah
,\ ._..e // er ii —r -
Kull resident address of apprrant(number and street,city,state,and ZIP code)
7110/ S. llao ZO 0/0er/5(h//e , 1/ ) '4764S
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and sheet city,state.and ZIP code) -
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