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STATEMENT OF MORTGAGE OR CONTRACT
INDEBTEDNESS FOR DEDUCTION FROM ASSESSED
VALUATION State Form 43709 (1-90) Prescribed by the
State Board of Tax Commissioners
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I sj �ctions for filing:
To i�iled 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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Applicant (Qwner or contract
on
Taxing Dish�fct P V d" I Key NumbedLegal Description
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Filin fee $1.00
Co o Year
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File Mark �
/� D TO�R ���� ��
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Record
No.
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Assessed value of real property as Mortgage/Contract Indebtedness unpaid Is the a licant the ole legal or
of March 1, current year as of March 1, current year. equitable wner? 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.
on record is different than that of applicant, indicate below:
�� � `jmortgagee or I
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��s of mortgagee or contract seller
of Assignee or other owner or holder of Mortgage.
of Assignee
Does applicant own real property I If yes, what county? What Taxing
in any other county in Indiana?
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
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Signature
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Flas this deduction been
requested on property for current
year? ❑ yes ❑ no
�?-6,���,� � �003 19 d
- � • 02 ��13 Pr?i�o
3rd of Review Date
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`stify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
�s/were a resident of Indiana and owner of the aforementioned property on March 1, 19 .
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-`.. ;e (owners full name) Person authorized by duly executed Power of Attorney or
���•.�0.._ , F .�_ �� by IC 6-1.1-12-.07).
ress of Aplicant � Address of Authorized Person