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.•�•�4 STATEMENT OF MORTGAGE OR CONTRACT Filin fee $1.00
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��., INDEBTEDNESS FOR DEDUCTION FROM ASSESSED County Township Year
� VALUATION State Form 43709 (1-90) Prescribed by the ,�
��.�• ' State Board of Tax Commissioners �� �
:;�f File Mark
ctions for filing: '� � 1. i991
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 deductio�v �. %K�,�u �s \�U�
is to be effective. See reverse for additional instructions and qualifications. AUDITOR °
Applica (Owner or contract buyer - see restrictions on reverse)
�
Taxing District Key Number/Legal Desc tion Record No. �`
DII �4
Q� � Page No. 7 a %r
Assessed value of real property as Mortgage/Contract Indebtedness unpaid Is the applicant the sol legal or
of March 1, current year as of March 1, current year. equitable owner? es O no
a000
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:
�e of mortgagee or contract seller
ess of mortgagee or contract seller
�1
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 o- property for curreni
year? �L�s ❑ no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
19 19�� 19��a 19 j 19�� � �_��.�
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Signature S creta of Board of Review Date i/
7-8-9% �,a-�• � o�r � � oe oq o�f>��
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
ts was/were a resident of Indiana and owner of the aforementioned property on March 1, 19
�ature (ow ers full name) Person authorized by duly executed Power of Attorney or
by IC 6-1.1-12-.07).
Full Re dent Address of Aplicant Address of Authorized Person
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