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STATEMENT OF MORTGAGE OR CONTRACT
INDEBTEDNESS FOR DEDUCTION FRdM ASSESSED
VALUATION State Form 43709 (1-90) Prescribed by the
State Board of Tax Commissioners
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Filin fee $1.00
r Township Year
Instructions for filing: - ' - ' - —
To be filed in person or by mail with the County Auditor of the county wh�h@ �'�98
property is located during the 12 months before May i 1 of the year the deduction �.
is to be effective. See reverse for additional instructions and qualifications.� � n
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File Mark
Applicant (Ow er or contract yer - ee res/t�ri'ctions o ers
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Taxing District Key Number/Legal Description Record No. _ a 6
-Q �% (�- � Page No.
Assessed vatue of real property as Mortgage/Contract Indebtedness unpaid Is the applicant the sole legal or
of March 1, current year as of March 1, current year. equitable owner? O yes O no
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If no, what is his/her exact share or interest? If owned with someone other than spouse,
indicate with whom.
If name on record is different than that of applicant, indicate below:
��me of mortgagee or contrac eller
Address of mortgagee or contract seller
Name of Assignee or other owner or holder of Mortgage.
Address of Assignee
Does applicant own real property If yes, what county? What Taxing District? Has this deduction been
in any other county in Indiana? requested on property for current
year? O yes D no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
19� 19��a 19�� 19�% �dD ,c 1$—� . �F9-3o�
L-31-0� %-a/- flz Pl�RBo�$-
Signature Secretary of Board of Review Date
�� o �05 �� ° ������
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
's was/were a resident of Indiana and owner of the aforementioned property on March 1, 19
i ature (owners full name) Person authorized by duly executed Power of Attorney or
o � ��� by IC 6-1.1-12-.07).
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Full Resident Address of Aplicant Address of Authorized Person