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STATEMENT OF MORTGAGE ONTRACT 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
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.
Applicant (Owner
3xi6(g District
P/��o`rt--
ee restrictions on reverse)
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Key Number/Legal Description
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File Mark
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Record
No. !o S'�
Assessed value of real property as Mortga§e Contract I ebtedness unpaid Is the applicant the sole legal or
of March 1, current year as of March 1, curr�t year. equitable owner? �s ❑ no
9om-�93 = 583o a�f, 000. �.c�oop,
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:
of mortgagee or contract seller
�ess of mortgage
Name of Assignee or
Address of Assignee
owner or holder of Mortgage. �j �
I
Does applicant own !eai 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 g/ 19�? 19�-0� 1
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Signature
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Secretary of BcYard of�eview
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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-
ts was/were 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 �
:. ,. � � . . _ %� . �a n -f'PI�A/1 by IC 6-1.1-12-.07).
Full Resident�Address of Aplic t Address of Authorized Person
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