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STATEMENT OF MORTGAGE OR CONTRACT
INDEBTEDNESS FOR DEDUCTION FROM ASSESSEO
VALUATION State Form 43709 (1-90) Prescribed by the
State Board of Tax Commissioners
Instructions forfiling:
To be filed in person�or by mail with the County Auditor of the county where the
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.
FEB 2 6 1999
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GIBSO�' COi!r! � v nnrnma
Applicant (Owner or con r t bu r- see tricti n o r v rse) -
Tax� g istrict Key Number/Lega Description Record No.
� r�''� ��� 1 O Page No. l�p g l0
As essed value of real property as. Mortgage/Contract Indebtedness unpaid Is the applicant the sole legal or
of March 1, current year as of Marc 1, currenQt yea�r. equitable owner? O yes � no
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:
,�ame of mortgagee or contract seller � �
Address of mortgagee or contract seller
Name of Assignee or other owner or hoider of Mortgage.
Address of Assignee
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 ❑ no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
19�-0 a 19� � 19Q74b2 �� _��/L t�b03 1�' �0 19
-al b- S-o� D �
Signature • _ Secretary of Board of Review Date
a� 09 � o �17��9
IIWe certify under penaity of perjury that the above and foregoing information is true and correct and that the appli-
�nts was/were a resident of Indiana and owner of the aforementioned property on March 1, 19
,.�gn ture (owners tull name) Person authorized by duly executed Power of Attorney or
by IC 6-1.1-12-.07).
Ful Resi�en A re�� of Aplicant Address of Authorized Person
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