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STATEMENT OF MORTGAGE OR CONTRACT INDE
FOR DEDUCTION FROM ASSESSED VALUATION
State Farm 43709 (R3 / 1400)
PresaibeC by State Boartl ol Tax Commissioners
FORM 5
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Instructions for filing: , �`jpF
To be filed in person or by mail with the County Auddor of the county where the property is :��; "� ,
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located during the 72 months before May 11 of the year the deduction is to be effective. See G`F�nCk �-
reverse side for additional instrudions and qualfications.
Appiipnt (ow r or conhact 6uyer- see sMctions on reverse sid ) n _,.
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Tauing District Key number / legal desuiption Record numbe� 1_
L/ / �� — G� Page number. ) �• 1
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Assessed value of real property as of Mortgage / Contred indebte ness unpaid as of Is the apptipnt the sole legal or equitable
March 1, current year Ma�1, current year ownef? ❑ Yes ❑ No
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If no, what is his her exad share of 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 contrad seller n
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Address of mortgagee or conVad seller (number and sheet, cit state, ZIP -
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sVeet, city, state, ZIP code)
Does applipnt own real property in any If yes, what county? What Taxing DisVict? Has this dedudion been requested on
other county in Indiana? property for current year? � Yes ❑ No
COUNTY AUDITOR
Dedudion appraved in the amount of:
20��%jga(� .20 � 20 20 � s 20 � 20 20 � 0
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Signature County Auditor Date
I/ We certify under lhe penalty of perjury that the above and foregoing information is We and corred and thal the applicants was / were
�ident of Indiana and owner of the aforementioned property on March 1, 20
Signa re ners /u na ) Person authorized by duly executed Power of Attomey
or by IC 61.1-12-.07 � •
Ful resident address of applipnt Address of author¢ed person