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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
Instructions for filing:
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
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Year
�,�, ,�. rr�+-3 �
AUD►TOR 1
A icant (Owner or con ra t buyer - see restr ctions o reverse)
Taxi District e umber/Legal Description Record No. �
°` G� �J V Page No. � �
A se sed value of real property as Mortgage/Contract Indebtedness unpaid Is the applicant the sole legal or
of arch 1, current year as of March 1, current year. equitable owner? O 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:
P' �e of ortgagee or co,ntf act seller
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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? �7 yes � no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
19�-� 19� 19_ 1�&� 19 19 J�e2 �` � �Z �QDa
9s-9'6 ,� � ,� g,a/
Signature Secretary of B ard of Review Date Q9 Q� �
� - a �-98 /<3, �-�- �' , � � oE ° . g 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�ature (owners full name) Person authorized by duly executed Power of Attorney or
by IC 6-1.1-12-.07).
Full Reside Address of Aplicant Address of Authorized Person