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�,.^pa4 STATEMENT OF MORTGAGE OR CONTRACT
a�°,� ; INDEBTEDNESS FOR DEDUCTION FROM ASSESSED
"• ' VALUATION State Form 43709 (1-90) Prescribed by the
•�e�• ` State Board of Tax Commissioners
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I��ctions for filing: ���;���s
To be filed in person or by mail wiih the County Auditor of the county where the ,i(UDITOR .
property is located during the 12 months before May 11 of the year the deduction ����'�J� „�
is to be effective. See reverse for additional instructions and qualifications. ���
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or contract buyer - see
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Taxing District
�strictions o�
Number/Legal Description
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Record No.
No.
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Assessed value of real property as Mortgage/Contract Indebtedness unpaid Is the applicant the sole legal or
of March t, current year as of March 1, current year. o0p equitable owner? O yes ❑ no
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If no, what is his/her exact share or interest? If owned with someone other than spouse,
indicate with whom.
If name on record is different than that of applicant, indicate below:
o��'o�G /3-�QG�66/. �a�3-GG/.
Name of moriaaqee or contract seller
mortgagee or contract seller
Name of Assignee or other owner or holder of Mortgage.
Does applicant own real property If yes, what county? What Taxing Disirict? Has this deduction been
in any other county in Indiana? requested on property for current
� � year? ❑ yes O no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
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6-/7- 9�"
19
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W ✓ {�
�ecretary of Board of ReOvi�w D�te aDOf/
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I/We certify under penalty of perjury that the above and foregoing information is t�ue and correct and that the appli-
cants was/were a resident of Indiana and owner of the aforementioned property on March 1, 19
�nature (owners full name) Person authorized by duly executed Power of Attorney or
,a,�� _ .� n by IC 6-1.1-12-.07).
Resident rAddress of Aplicant
Address of Authorized Person