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,.�. 4 STATEMENT OF M A Filin fee $1.00
e i INDEBTEDNESS FOR DEDUCTION FROM ASSESSED County Township Year
� .�` VALUATION State Form 43709 (1-90) Prescribed by the
�: State Board of Tax Commissioners
File Mark
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. �
Applicant
District
Key Number/Legal �escription � Record No.
.� �CS f—Ck> Page No. � I J�
Assessed value of real pro erty as Mortgage/Contract Indebtedness unpaid Is the appiicant the sole legal or
of March 1, current year as of March 1, current year.' 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:
of mortgagee or contract seller
Address of mortgagee or contract seller
Name of Assignee or
ress of Assignee
owner or holder of Mortgage.
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:
199�0� 19 � 19 b0'�
� �1 ss �-a�-ai
Sign�a�tui
o`^' �
; .... i � �
�
—�/�— a'i. I / �/�ci
Secretary of Board of Review
3 .'ZO o'� �.9 � o �
�,-?lt3oA �
Date
�/�o l�'
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
�nts was/were a resident of Ind a and owner of the aforementioned property on March 1, 19 .
opgr�at e w�f c nam Person authorized by duly executed Power of Attorney or
y v by IC 6-1.1-12-.07).
Address of Aplicant „ � I Address oi Authorized Person