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STATEMENT OF MORTGAGE
INDEBTEDNESS FOR DEDUCTION
VALUATION State Fo�m 43709 (1-90
State Board of Tax Commissioners
OR CONTRACT
FROM ASSESSED County Township Year
) Prescribed by the �
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Instructions for filing:
To be filed in person or by mail with the County Auditor of the county where the FE� 2 ti 20��
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. �;;',U���,i•'
GISSO."� r ... T♦ e.U0.1C•O
Ap ' t Owner ntr�buy see re ictions on r v rs
Taxi istrict � Key Number/Legal Description Record No.
W��11�� D���tJPSS%��-U PageNo. '
Assessed value of real property as Mortgage/Contract Indebtedness unpaid Is the applicant the sole legal or
of March 1, current year as of h. current year. equitable owner? rJ yes � no
�� �28 ��
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
ddress 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�Q'j�, t��b' �� � },8 e 19
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Signature 0 � _ Secretary of Board of Review Date
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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
atur (owners full na ) Person authorized by duly executed Power of Attorney or
by IC 6-1.1-12-.07).
esident Address of Ap ant Address oi Authorized Person
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