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STATEMENT OF MORTGAGE
INDEBTEDNESS FOR _DEDUCTION
VALUATION State Form 43709 (t-90
State Board of Tax Commissioners
OR CONTRACT
FROM ASSESSED
) Prescribed by'the
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FORM 5
fee $1.00
Township Year
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File Mark
Instructions for filing: `— Z���
To be filed in person.or by mail with the County Auditor of the county.where thesj;!_ 1 2. �
property is located during the 12 months before May 11 of the year the deduction - f �
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is to be effective. See reverse for additional instructions and qualifications'.� �--• , �J,�-��"�
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Applicant (Owner or ontra b -see restrictio2spn r v rse) -
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Tax g District - Key Number/Legal Desc ti n Record No.
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Assessed valUe of real property as Mortgage/Contract Indebtedness unpaid Is the applicant the sole legal or
of March 1, current year as of Marc cy�rgnt �ar. equitatile owner? O yes ❑ no
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If no; what is his/her exact share or interest? If oylned with someone other than spouse,
indicate with whom.
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If name on record is different than that of:applicant, indicate below: ..
��e of mortgagee or contract seller
Address of mortgagee or contract seller •
Name of Assignee or other owner or holder of Mortgage.
Address of Assignee , � ' � _ . .
Does applicant own real property If yes, what county? What Taxing District? Has this deduction been
in any other county in Indiana? requested on property for current
year? O yes ❑ no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
Year��— Ye��a(� Yeara�.d.�— Year Year � Year Year ��
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Signature 0$ 09 Secretary of Board of Review Date
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I(We certify under penaity of perjury that the above and foregoing information is true and correct and that the
licants was/were a resident of Indiana and owner of the aforementioned property on March 1,
^ ign re (owner II name) Person authorized by duly executed Power of Attorney or
' by IC 6-1.1-12-.07).
�II sid ni Address of Applicant Address of Authorized Person
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