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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
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,,. FOR DEDUCTION FROM ASSESSED VALUATION
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- State Form 43709(RI I/6-09)
Presmbed by Department of Local Government Finance („
INSTRUCTIONS:
lb be filed in person or by marl with the County Auditor or County Recorder of the county where the property is located. Form filed with:
Filing Dates: 1) Real Properly:Must file during the year for which the deduction is sought. e CT M2'' y Auditor
2) Mobile I Manufactured Homes not assessed as Real Property:Must We during the twelve(12)months
before March 31 of each year the deduction is sought ❑ County Recorder
See reverse side for additional instructions and qualifications. I /ri0111t±i
Apprxant(ownpr or contract buyer-see on reverse side) GIBSON COUNTY AUDITOR
T 'ng D� Key number/legal des 3. 'Record number Page number
a(o - l4- 3l - X00 - ooh- yon -o � y 13 r5 �G
valued real properly as of Motgagge/Comma indebtedness unpaid as of Mortgage I Contract cWebtedness'uunpaid as d Is the applicant the sole
1,current year Marti 1,cortent year date of application legal or equitade Amer?
l y ' 5 0 o I ❑ Yes ❑ No
If no,what is his/her exact share of interest? r If owned with someone other than spouse,mdirate with whom
If name on record is different than that of applicant,indicate below: .Is_th,/a property in question:Annually Assessed
Ind Real Property ❑Annually Assessed
T� Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller —..
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Address of mortgagee or contract seller(number and street,city,state,a'ZIP code) (
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Name of assignee or other owner or holder of mortgage —343\\(..)SO�) 16G`f�-- ��
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Address of assignee(number and street,city,state,and ZIP code)
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Does applicant own property in any other If yes,what county? • What Tai - 1 2 VJ,, •
county in Indiana? ❑ Yes J
❑ No a No
COUNTY AUDI TOF I
Deduction approved in the amount of
20 20 20 20 20 120 20
Signals o rg f Caa:ry Auditor' • County I Date(month,day,year)
I 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 I contract buyer of the aforementioned property on date application is filed.
/Signature(owners full aul
name) Date(month,day,year)
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resident dress of appricant(number and street,city,state,and ZIP code)
r)q C.. \-oa5 S . %-\os..sbst'ca.d+ \o..1 t.a1 (o3q
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 I Date(month,day-)ear)
Address of authorized person (number and sheet d0:state,and ZIP code) . I ..