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STATEMENT OF MORTGAGE OR CONTRACT
INDEBTEDNESS FOR D.EDUCTION FROM ASSESSED
VALUATION State Form 43709 (1-90) Prescribed by the
State Board of Tax Commissioners
FORM 5
fee $1.00
Township Year
. . . � �� FiI�Ma
Instructions for filing: ._, . �+�IY �� 2�00
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 deducNtin � � n'
is to be effective. See reverse for additional instructions and qualifications.� �,��y.�� ,,!!. V
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Applic nt (Owner or contract buyer - see restrictions on revers ) -�
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Taxing District ; ey Number/Legal Des � n Record No. _' L1 L! ��
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Assessed value of real property as Mo age/Contract Indebtedness unpaid Is the applicant the sole legal or
of March t, current year as March 1, current year. equitable owner? ❑ yes ❑ no
If no, wliat is his/her exact share or interest? � If owned with someone other than spouse,
indicate with whom. '
If name on record different than th f applicant, in te b low:•. - '
�'-�e of mortgagee or cont� seller
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Address of mortgagee or contract seiler : � . •
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 Year /� � d� � a'3 �r� Year �� Year 'IbL Year po
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Signature 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,
Si nat (owners full name) Person authorized by duiy executed Power of Attorney or
/ _ by IC 6-1.1-12-.07).
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Full Re ent Address of Applicant Address of Authorized Person