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STATEMENT OF MORTGAGE OR f
INDEBTEDNESS FOR DEDUCTION FRO
VALUATION State Form 43709 (1-90) Presc
State Board of Tax Commissioners
Instructions for filing:
To be filed in person or by maii with the County Auditor of the
property is located during the 12 months before May 11 of the �
is to be effective. See reverse for additional instructions and
Applicant (Owner or
T
.
Assessed value of
of March 1, current
- see
Key
er/Legal Description
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Record No.
No.
as IMortgage/Contract Indebtedness unpaidl Is the applicant the sole legal or
as of March,l, �rurrent,ye� equitable owner? L7 yes O no
If no, what is his/her exact share or
If owned with someone other than spouse,
indicate with whom.
If name on record i different than tha of applicant, indicate below:
��e of mortgage o contrac se
Address of mortgage r contra seller
Name of Assignee or other owner or holder of Mortgage.
of Assignee
t. ♦
Does applicant own !eal property If yes, what county? What Taxing District? Has this deduction been
in any other county in Indiana? requested on property for current
year? ❑ yes J no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
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Signature
19�_Q 0'�
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G- �6• a� I G.co
Secretary of Board of Review Date
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/ I —99 /�_e1 P i/�
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I/We certify under penalty of perjury that the above and foregoing ir�formation is true and correct and that the appli-
s was/were a resident of Indiana and owner of the aforementioned property on March 1, 19
s�gn ture (owners f I na�m{7e) /� , Person authorized by duly executed Power of Attorney or
-�k�%�� �-V�..e.�-�� by IC 6-1.1-12-.07).
Resident dr�ss of Apiic t Address of Authorized Person
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