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STATEMENT OF MORTGAGE
INDEBTEDNESS FOR DEDUCTION
VALUATION State Form 43709 (1-90
State Board of Tax Commissioners
OR CONTRACT
FROM ASSESSED
) Prescribed by the
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.
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NOV 16 2000
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Applicant ( wner or contract buyer - see restrictions on reverse)
Tax'ing District Key Number/Legal Description Record No.
. �p Page No.
Assessed value of real pr perty as Mortgage/Contract Indebtedness unpaid Is the applicant the sole legal or
of March 1, current year as of March 1, current year.5�,.p�. 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:
Name of mortgagee or contract seller
Addre s of mortgagee or contract seller '
Name of Assignee or other owner or hoider 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 rJ no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
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Signature _ Secretary of Board of Review Date
I/We certify under penalty oi 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
��gn ure (owne s f il ame) Person authorized by duiy executed Power of Attorney or
• � by IC 6 1.1-12-.07).
Fu I esi ent Address of Aplicant Address of Authorized Person
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