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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS .h/ ship Year
FOR DEDUCTION FROM ASSESSED VALUATION
odState Formby 43709
Department R11 nt of L NOV
Prescribed by Departrnent of Local Government Finance 0 013
File Mark
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor or County Remnfer of the county where the property is 1 h1ed
Filing Dates: I) Real Pmpertç Must file during the year for which the deduction is sought GIBSON COUNTY A ITainty Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)month.
before March 31 of each year the deduction is sought County Reorder
See reverse side for additional instructions and qualifications.
(ownHamnrrdrtb mmsfmn Arse side (�
Taxing O . �n1rn1 Key number/legal description f`-1n",l/ Record number Page number
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Assessed value of real property as of Mortgage/Contact indebtedness unpaid as of Mortgage/Contact ckebtednesa unpaid as of Is the applicant the sole
Mardi 1,aareot year March 1,anent year date of application legal or equitable owner?
(1) U/4,bo I Dyes 0 N
If o,what is his/her exact share of interest? I If owned with someone other than spouse,Indicate with whom
If name on naard is afferent than that of applicant indicate below:
Name of mortgageepytra
�^ ct seller
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Address of mortgagee or contract surer(number e street,cry,sag.and ZIP I r_l
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,cry,state,and ZIP code) r�y�`u^L•.�
Does applicant ova property in any other If yes,what county? • v/y-t_C9— C• ` - a ' Ir
county in Indiana? ❑ No _
❑ Yes Q
o� O 1, E.-0-0e—• o�-
Deduction approved in the amount of:
20 20 20 Signature of County Auditor s_....a nd I — 50 5 `% -
I I We certify under the penalty of perjury that the above and foregoi
owner I contract buyer of the aforementioned property on date appli. _
Itigna (o es hAl r{grreg
1
Full ens address of applicant(number and rime,city,state,and VP code)
1 (s cL/c5 Z/n/co/it/' Dar('/a-,t) e/76j Al 9'7(4.o
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of autleliced person (number and street,cis state,and ZIP code)