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STATEMENT OF MORTGAGE OR CONTRACT
INDEBTEDNESS FOR DEDUCTION FROM ASSESSED
VALUATION State Form 43709 (1-90) Prescribed by the
State Board of Tax Commissioners�
FORM 5
Filin fee $1.00
. County Township Year
File Mark
Instructions for filing:
To be filed in person or by mail with the County Auditor of the county where the � r�( ` �pt �
property is located during the 12 months before May 11 of the year the deduction � 5 �'��11'!-
is to be effective. See reverse for additional instructions and qualifications. �°- �' ��`
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Appti er or contract buyer - see r trictions on reverse)
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Taxin DiAstrict /' Key Number/ gal Description Reeord No.
C/���Ct.�.( `% � ���o - D C%��—�J�d , Page No. S�
Assessed value of real propert as Mortgage/Contract�lndebtedness unpaid Is the applicant the sole legal or
of March t, current year as of Maroh current year. equitable owner? O yes O no
If no. whaf is hislher'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:
��-ne of mortgagee or contract seller
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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 rJ no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
Year Year � a' r J ✓ Year Q�_ Yeay�� Year -? nOJ� Yea�
� - -6 (o [0 7A-�d p
Signature Secretary of Board of Review Date 2 o a%-/�
a 1-
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the
olicants was/were a resident of Indiana and owner of the aforementioned property on March 1,
Signature (owners full name) Person authorized by duly executed Power of Attorney or
by IC 6-1.1-12-.07).
Full esident Address of Applicant Address of Authorized Person
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