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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
:: FOR DEDUCTION FROM ASSESSED VALUATION
• )..t State Form 43709(R11/609)
Presoibed by Department of Local Government Finance �r FIJI(
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INS7RUC77ONS: _
7o be filed in person or by mail with the County Auditor or County Recorder of the county where the property is bred.t Form filed with:
Filing Dates: 1) Real Properly:Must file during the year for which the deduction is sought U C L 12 O rfl County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months
before March 31 of each year the deduction is sought. - ❑ County Recorder
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See reverse side for additional instructions and qualifications. - {
Applicant • or contract buyer-see restrictions on side/)1r�1� �_ GIBSON COUNTY AUDITOR
Taxing r Whitt - / Key number/legal desaipkG / Relco�rd number/ Page n�/`ev
Assessed -of real. ...'/as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the apprcant the sole
March 1;anatyear / Mardi 1,current year date of application legal or equitable owner?
C3
o .P,/- 0o o ID Yes 0 No
If no,what is his I her exact share of interest? If awned with someone other than spouse,indicate with whom
If name on record is deferent than that of apprxant,indicate below. Is the property in queston:AnnualyAssessed
❑Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller if n _- �/1 s_- `�-
Address of mortgagee or contract seller(number and street,city'cistaatatee,and ZIP code)))
Name of assignee or other owner or holder of mortgage
AddresA of assignee(number and sheet city state,and ZIP code)
• T Ai L. (n - 3 —// 77. .3
/ Y 4-) -
Does applicant awn property in any other If yes,what county? • i - Bed on property
county n Indiana? /
/
❑ Yes ❑ No a / Yes El
Drawer NO l fill
coup 5-5
Deduction approved in the amount of -
Card NO. `
20 20 20 20 20
.
Signahaer 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. .
SI tire(owners full name) Date(month,day,year)
CO Ltd(I .rn p j )
Full resident address of applicant(number and street trey,state,and ZIP code)
k 5Byl W• g5TS. OM nSvl I le, In Ii11n[95
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) .