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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sfafe Fortn 43709 (R3 / 10-00)
PrewibeE bi State Board of Tax Commissioners
InsVuctionsforfiling:
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 oi the year the dedudion is to be effective. See
reverse side for additional insWCtions and qualfications.
FORM 5
Coun Township Year
File Mark
NOV O 1 2001
GIB/�NTY AUDITOR
Applicant (ownerorcontract buyer- see resUictions on reve e side) . • ,
Taxing Distrid Key number / legal description Recor number ^(
`� 1
� ^ � Page number ^ ,� l
Assessed value real property as of Mortgage / ConVact indebtedness unpaid as of , Is the appliqnt the sole legal or equitable
March 1, curtent r , March 1, current year owne(? ❑ Yes ❑ No
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If no, what is his / her exad share of interest? J If owned with someone other than spouse, indicate wifh whom.
If name on record is d'rfferent than that of applicant, indicate below:
� of mortgagee or contrad seller -- .
Address of mortgagee or contrad seller (number and street, city, sfate, ZIP '
Name of assignee or other owner ar holder of mortgage
Address of assignee (number and street, aty, state, ZIP code)
Does applicant own real property in any If yes, what county? What Taxing DisVid? Has this dedudion been 2quested on
other county in Indiana? property for current yeaf? ❑ Yes� No
COUNTY AUDITOR � �
Deduction approved in the amount of:
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Signalure O� County Auditor Date
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�. e certi(y under the penalty of perjury that the above and foregoing informatlon is We and cortect and that the applicants was / were
ident of Indiana and owner of the aforemenlioned property on March 1, 20
Signature (owners full name) Person authorized by duly.executed Power of Ariomey
or by IC 6-1.1-12-.07
Ful ident addre f ap li nt Addreu of author¢ed person
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