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STATEMENT OF MORTGAGE OR
INDEBTEDNESS
VALUATION Stat
State Board of Tax
Instructions for filing:
FOR DEDUCTION
e Form 43709 (1-90
Commissioners
CONTRACT
FROM ASSESSED
) Prescribed by the
To be filed in person or by mail with the County ALditor of the county where the
property is located during the 12,months before May 11 of the year the deductiqn
is to be effective. See reverse for additional instructions and qualifications. ,k,
Applicant (Owner r ontract buyer - see restr ons on reverse) '
Taxing District Key Nu er/L gal_Descri tion Record No. _�-4—�
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C���YI�iJIN � �� —�0� � 3 " �� 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 March t, current year. equitable owner? O yes � 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 contr�ct 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? ❑ yes ❑ no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
19 19_�_�b2 �D�a� t3 �3 19 � 19 19 a
�5 (0'1l -61 �
Signature 0 �� _ Secretary of Board of Review Date
P P �
INVe certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
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ts was/were a resident of Indiana and owner of the aforementioned property on March 1, 19
Signature (owners full name) _ Person authorized by duly executed Power of Attorney or
.,C�i �y by IC 6-1.1-12-.07).
Fu eside ddress of Aplicant Address f Authorized Person
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