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STATEMENT OF MORTGAGE OR CONTRACT
INDEBTEDNESS FOR DEDUCTION FROM ASSESSED
VALUATION State Form 43709 (1-90) Prescribed by the
5tate Board of Tax Commissioners
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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.
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Applicant ( er or contract yer;�see rest �ons on�re-verse)
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T District Key Nu dLegal Description Record No. /� 9 2
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Asse d 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, 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:
Name of mortgagee or contract selier , �
�ress of mortgagee or contract seller
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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 REVIEW ACTION
Deduction approved in the amount of:
19 S3 _�j+j 19 ��' 19� � 19�-(� � 19�60..2 �3 ��n3
61�41� ��-�i - a -o
Signature G-n � 1�� Secretary of B ard of Review Date �
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I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
�ts waslwere a resident of Indiana and owner of the aforementioned property on March 1, 19
�.iature (owners ful me) Person authorized by duly executed Power of Attorney or
by IC 6-1.1-12-.07).
II Residenf A�ddr s plicant Address of Authorized Person