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STATEMENT OF MORTGAGE OR CONTRACT
INDEBTEDNESS FOR DEDUCTION FROM ASSESSED
VALUATION State Form 43709 (1-90) Prescribed by the
State Board of Tax Commissioners
Filinct fee $1.00
Instructions for filing: � �-`"—
To be filed in person or by mail with the County Auditor of the county where the ,� � 2�Q�
property is located during the 12 months before May 11 of the year the deduction � tg (,
is to be effective. See reverse for additional instructions and qualifications. • �� (� �
Year
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Applicant (Owner or contra t buye - see r strictions o erse) '
Taxing District Key Number/Legal Descriptio Record No. OQ
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Assessed value of real propert as Mortgage/Contract Indebtedness unpaid Is the applicant the sole legal or
of March 1, current year as of MaGrch 1, current year. 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:
Name of mortgagee or contract sell
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ddress of mortgagee or contract seller
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Name of Assignee or other owner or holder of Mortgage.
Address of Assignee ' �
Does applicant own real 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 ❑ no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
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Signat re p� pq _ Secretary of Board of Review Date �1g°J-P
P e
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
� �ts was/were a resident of Indiana and owner of the aforementioned property on March 1, 19
�nature (owners f name) Person authorized by duly executed Power of Attorney or
by IC 6-1.1-12-.07).
Full Resident ss of Aplicant Address of Authorized Person