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STATEMENT OF MORTGAGE OR CONTRACT
INDEBTEDNESS FOR DEDUCTION FROM ASSESSED
VALUATION State
State Board of Tax
Form 43709 (1-90) Prescribed
Commissioners
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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Applic (Owner or contract bu er - see restrictions on reverse)
Ta District Key NumbedLegal Description Record No. 5
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Jl,l�u� 021 Page No. �
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.✓ 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:
�e of mortgagee or contract seller / y_ / /) ,
/jSr .l`rC�
Address of mortgagee or contract seller
Name of Assignee or other owner or holder of Mortgage. n (�
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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? O yes O no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
19� 19 r6`� 19 19�662 oea - 03 {�03 _QQ C�
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Signature Secretary of Board of Review Da�
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ILWe certify under penalty of perjury that the above and foregoing information is true and correct and that the appli-
S�, waslwere a resident of Indiana and owner of the aforementioned property on March 1, 19
ature (owners full name) Person authorized by duly executed Power of Attorney or
by IC 6-1.1-12-.07).
Full Resident Address A nt Address of Authorized Person �/