HomeMy WebLinkAboutMortgage_Lemmons. �_,_
FORM 5
•T.T• STATEMENT OF MORTGAGE OR CONTRACT Filin fee $1.00
1a. p44
a�a;; 4 INDEBTEDNESS FOR DEDUCTION FROM ASSESSED. County Township Year
.�� VALUATION State Form 43709 (1-90) Prescribed by the
State Board of Tax Commissioners
� .4 =— ;� •File Mark
Instructions for filing: �� � s;� ` �,
To be filed in person or by mail with fhe County Auditor of the county where th�� E..,%.�;.f .�..J`
property is located during the 12 months before.May 11 of the year the deduction '�Y � �.2U��
is to be effective. See reverse for additional instructions and qualifications.
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or contract b�er - eE
restrictions on reverse) """"`
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Taxing�� • j Key Number/Legal Description
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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 Mar curr equitable owner?�O yes O no
;�ov
if no, what is his/he� 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
of mo�tqaqee or contract seller
of Assignee or other owner or holder of Mortgage.
Address of Assignee
� i
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 � � � Year�bp�
.2 �'p
Signature
d�a7 -i° �}, o
�� I Year aAt13 I Year 200
Secretary of Board of Review
Year
Date
Year �
I/We certify under penalty�of perjury that the above and foregoing information is true and correct and that the
applicants was/were a resident of Indiana and owner of the aforementioned property on March 1,
�_ ,
(owners full
af Ap�li
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Person authorized by duly executed Power of Attorney or
by IC 6-1.1-12-.07).
Address of Authorized Person