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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
Filin fee $1.00
County Township Year
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@�]A� 1= 19�i1e Mark
Instructions for filing: D�
To be filed in person or by mail with the County Auditor of the county where th�� �. r�. �
property is located during the 12 months before May t t of the year the deduction AUDITOR� �,�
is to be effective. See reverse tor additional instructions and qualifications.
Applicant (Owner r contract buyer - see restrictions on reverse)
Taxing District Key Number/Legal Description Record No.
1 Q — o�� '(�% 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 Marc 1, current year. equitable owner? O yes O 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:
-�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? �7 yes � no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
19��� 19� 19_�'—DO � 9�0 � 19� �- 1, 1
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Signature Se retary of Board of eview Date � ey � b
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T Lu�i-
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
-�_waslwere a resident of Indiana and owner of the aforementioned property on March 1, 19
,Sipnature (owners full name) Person authorized by duly executed Power of Attorney or
Xby IC 6-1.1-12-.07).
Full Resident Address of Aplicant Address of Authorized Person
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