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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
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Instructions for filing: �q�����k
To be filed in person or by mail with the County Auditor of the county where the a� �
property is located during the 12 months before May 11 of the year the deduction g�v. � 19�j �.
is to be effective. See reverse for additional instructions and qualifications.
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Applicant (Owner or con buyer - see restric "on on ve e) .
Taxi Di rict _ Key Number/Legal Desc iption Record No. �
Q Q � Q Q �— �Q Page No. �
Assessed value of real�property as Mortgage/Contract Indebtedness unpaid Is the applicant the sole legal or
of March 1, current year as of March/I ,�rent yearo � 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: -
�e of mortgagee or contract seller
Address of mortgagee or contract seller . • -
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? O yes o no
COUNTY BOARD OF REYIEW ACTWN a
Deduction approved in the amount of:
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Signature Secretary of Board of Review Date Og P
IO `� F/ � aG6E aba'-� P
I/We certify under penalty of perjury that the 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
S��nature (owners full name) Person authorized by duly executed Power of Attorney or
by IC 6-1.1-12-.07).
ull Resident ess o Aplicant Address of Authorized Person
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