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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
0 vim;; FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R71/6-09)
Prescribed by Department of Lod Government Finance
ja lr1 INSTRUCTIONS: . E A 11 .
To be filed in person or by mad with the County Auditor or County Recorder of the county where the property is located. Fe
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Filing Dates: 1) Real Properly.Must file during the year for which the deduction is sought D r LOtynly Auditor
2) Mobile/Manufactured Homes not assessed as Real Properly Must file during the twelve(12)months 1, 1 ty g!1 f.r
before March 31 of each year the deduction is sought On Ret+dfd
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See reverse side for additional instructions and qualifications. /)i
.. �. > orcontxquyer-see on reverse ) GIBSON
0 4An /� �� W COUNTY AUllrrn�Key J �� d Lion Record mrmb PPage
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Assessed vatic of real property as of I 6bngage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the app&rart the sole
March 1:=rent year I Mar d r=Tour year date of trn legal or equitable wme?
NWO ❑ Yes ❑ No
If no,what is his/her exact sham of interest? If owned with eone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Iss property in question:Annually Assessed
Real Property ❑An untlyAssessed
/(` / (T Mobile Home(IC 6r1.1-7)
Name of mortgagee or contract seller -
•
Address of mortgagee or contract seller(number and street te,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,dry,slate,and LP code)
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Does applicant own property in any other If yes,what county? • What Taring Disrn Has this deduction been requested on p
county in Indiana? ❑ NO • for runent yeah ❑ Yes ❑ No
El yes
COUNTY AUDITOR
Deduction approved in the amount at ,LQ.116Qt. ^
20 20 1� J OI� 20 20
Drawer NO �°TC
Signature of County Auditor Date(month.day,year)
I 1 We certify under the penalty of per Card NO. y° °� 1 ect and that the applicant is a resident of Indiana and
owner I contract buyer of the aforem_
Sign o _ /� ��C/J////J Date(month,day,year)
F / • u r � o sta ant LP code) // / '/ _i ) . . /6 0
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authorized by Judy erected Power of Attorney or by IC 1Y1.1-1 Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code) .