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STATEMENT OF
INDEBTEDNESS FO
VALUATION State Fo
State Board of Tax Co
Instructions for filing:
MORTGAGE OR CONTRACT
R DEDUCTION FROM ASSESSED
rm 43709 (1-90) Prescribed by the
mmissioners I , �
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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.
Filin fee $1.00
Cou ty Township Year
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A caqt ( n or contract b er� see restrictioy�on r e e) . -t
! VJ AUDITOR
axin District Key N er/Legal Description Record No.
• a� Page No. O �
. Assessed value of real property as Mortgage/Contr t Indebtedne s unpaid Is the applicant the sole legal or
of March 1, current year as of March 1, current year. equitable owner? O yes O 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 rt ee or contract seller
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Address of mortg e 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? ❑ yes O no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
�s�L �s 98 is��-o� is� ( is��- }�oor ks'aoa
/000 � —a�.ol o�. �
Sign�ture S cretary of Bo rd of Review Date
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IlWe 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
Signature (owners full name Person authorized by duly executed Power of Attorney or
� by IC 6-1.1-12-.07).
Full Resident Address of Aplicant Address of Authorized Person
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