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STATEMENT OF MORTGAGE OR CONTRACT Filin fee $1.00
INDEBTEDNESS FOR DEDUCTION FROM ASSESSED County Township Year
VALUATION State Form 43709 (1-90) Prescribed by the
State Board of Tax Commissioners (�
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for filing: ���e•�FS7�
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To be filed in person or by mail with the County Auditor of the county where the ���
property is located during the 12 months before May 11 of the year the deduction
is to be effective. See reverse for additional instructions and qualifications. \ F� g 2��ggi J
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Applicant (Owner or contr uyer - see restrictions on reverse) -t
• AUDROR
Taxing District Key Number/Legal Description Record No. ( �
. �q-o �a ,o
C� a� • Page No. I75a �
Assessed value of real property as Mortgage/Contract Indebtedness unpaid Is the applicant the sole legal or
of March 1, current year as of March 1, current year. � ppp.wl equitable owner? O yes ❑ no
I � 30 - 70 �O �u >
If no, what is his/her exact share or interest? � If owned with someone other than spouse,
indicate with whom.
If name on record is different than that of applicant, indicate below:
Name of mortgagee or contract seller .
-� „
�, ress of mortgagee or contract seller
Name of Assignee or other owner or holder of Mortgage. •
Address of Assignee
Does applicarit own real property If yes, what county? What Taxing District? Has this deduction been
in any other county in Indiana? requested on property for current
year? O yes ❑ no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
19 (� 19 9� 19�'-'�0 19 190� OO,i nW�bl� r0ea3
��.Il a �£$ �'a� " �� U , p �
Signature Secret of Board of Review Date
�� aaos-,� od o� oY��}ba�-�
7-8'-5b' ,�. �. O'
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
,� v,ure (owners full na e) Person authorized by duly executed Power of Attomey or
by IC 6-1.1-12-.07).
Full Resident Addr ss o Aplican ; Address of Authorized Person J
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