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4,W-t..‘ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
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�:. FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R11/6-09)
Presaibed by Department of Local Government Finance ars Ifl
INSTRUCTIONS: Ilri •1
--•with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is local-..
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought. neoely Auditor
2)Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months AY H7 Lux
before March 31 of each year the deduction is sought - 1 County Recorder
See reverse side for additional instructions and qualifications.
Applicant(owner or co��nb°�pct buyer-see restrictions �?''(�arse sail r
\/J2AJkC'r. 3'la�xC� - A. GIBBON COUNTY AUDITOR
Taxing District tier/legal d lion RemN number P e
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Assessed value of real property as of Mortgage/Contract GWebtedness unpaid as of Mortgage/Contract BMeb ess unpaid as of Is the applicant the sole
March 1,nand year Mardi 1.wrtrp date of application legal or equitable owner?
❑ yes ❑ No
if no,what is his/her exact share of interest? 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 ❑Annually Mobile Assessed
^ Moe Home(IC 6-1.1-7)
Name of wee or contract setter 1 t U
Address of mortgagee or contract seller(number and sb etCity.con s...r 710.....4_.. •
An xerox � `7
Doe CI (.,-3 7 District? Has this dedumon been requested on property
con d\ for current year?
.'r1t ❑ Yes ❑ No
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r7 ` 20 20 20
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Sign - C , �p Date(month,day,year)
I, t and correct and that the applicant is a resident of Indiana and
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Sign Date(mach,day,year)
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ant address of appfrvnt(number and thee(city,state,and ZIP code)
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authorized by duly executed Power of Aborney or by IC 6-1.1-12-0.7 . Date(month,day,year)
Address of authorized person (number and street atyt state,and ZIP code) _