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STATEMENT OF MORTGAGE O CONTRACT
INDEBTEDNESS FOR DEDUCTION FROM ASSESSED
VALUATION State Form 43709 (1-90) Prescribed by the
State Board of Tax Commissioners
Instructions for filing:
To be filed in person or by mail with the Couniy Auditor of the county where the
property is.located during the 12 months before May 11 of the year the de ction � a_
is to be effective. See reverse for additional instructions and qualifica ons,� ,
Applicant (Owner
Taxing District
Assessed value of,f�al property as
of �M/a�rch 1, currenty�ear
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�AUDITOR
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Key Number/Legal Descripti n Record iSC
�.% �� /a� 7 Page No. c� /SS
Mortgage/ ontract Indebtedness unpaid Is the applicant the ole legal or
as of March�l� c�u�eni year. equitable owner?�yes O no
If no, what,is hislher 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:
�of mortgageef�oi
Address of mortgagee
Name of Assignee or
Address
or
-'
Does applicant own real property If yes, what county? What Taxing District? Has ihis 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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Signature
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Secretary of Board of Review I� Date aB-e 7 p$ �
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certify under penalty of perjury tWat the above and foregoing information is true and correct and that the appli-
�Nas/were a resident of Indiana and owner of the aforementioned property on March 1, 19
it��e (owners full name) Person authorized by duly executed Power of Attorney or
` . . . � ' _ / _ by IC 6-1.1-12-.07).
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Address of Aplicant � Address of Authorized Person