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STATEMENT OF MORTGAGE O CONTRACT
INDEBTEDNESS FOR DEDUCTION FR M ASSESSED
VALUATION State Form 43709 (1-90) Pre
State Board of Tax Commissioners
Instructions for filing: I
To be filed in person or by mail with the County Auditor of the county re he
property is located during the 12 months before May 11 of the year the deduction
is to be effective. See reverse for additional instructions and qualifications.
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AUDITO
Appl� a t(Owner ontract bu r- ee restrictions on reverse)
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Taxing Dist i t Key Number/Le al Description Record No.
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Assessed value real property as Mortgage/Contract Indebtedness unpaid Is the applicant the sole legal or
of March 1, current year as of March 1, curr nt year. equitable owner? ❑ yes O no
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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:
� e of mortgagee o contract seller
Address of mortgagee or contract seller ' ll �` �Q
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Name of Assignee or other owner or hotder 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 Indiane? requested on property for current
year? �7 yes O no
COUNTY BOARD OF REVIEW ACTION
Deduction approved i� the amount of:
19,�,3•�i� 19 '� 19� ( 19 OD2 �,��L 19� 19�
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Signature Secretary of Board of Review Date apor � � 8�
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I/We certify under penalty of perjury that t e above and foregoing information is true and correct and that the appli-
> was/were a resident of Indiana and owner of the aforementioned property on March 1, 19 .
��,gnature (owners full name) Person authorized by duly executed Power of Attorney or
��� ��� by IC 6-1.1-12-.07).
Fu I Resident Address of Aplicant Address of Authorized Person
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