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STATEMENT OF MORTGAGE OR CONTRACT
INDEBTEDNESS FOR DEDUCTION FROM ASSESSED
VALUATION State Form 43709 (1-90) Prescribed by the
Siate Board of Tax Commissioners
Instructions for filing: �
To be filed in person or by mail with the County Auditor of the county where the AUG 20 �ggg
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 (Owner o contract buyer - see estri tions on_�J��- •
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Taxi District Key Number/Legal Description Record No.
\JO� O� J Q v Page No. �%�
Assessed value ai property as Mortgage/Contract Indebtedness unpaid Is the applicant the sole legal or
of March 1, curre t ear as of M rch 1,OcurQrer�year. equitable owner? O yes ❑ no
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Ii 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:
ame of mortgagee or contract seller
S
Address c?f mortgagee or contract seller
Name of Assignee or other owner or holder of Mortgage.
Address of Assignee
Does applicant own !eal 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 ❑ no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
19� pd 19_ yry� 19� � a3 �6.Q� 19 D!l 19�
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Signature Secretary of Board of Review Date
y°°� a�o�-P � ° �� �����'9
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 Indiana and owner of the aforementioned property on March 1, 19 .
��gnat (o ners ful a ) Person authorized by duly executed Power of Attorney or
by IC 6-1.1-12-.07).
Resident Ad ress of icant Address of Authorized Person
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