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STATEMENT OF MORTGAGE OR CONTRACT INDE
FOR DEDUCTION FROM ASSESSED VALUATION
State Fartn 43709 (R3 / 10-00)
Presaibed by State Boartl ol T� Commissioners
FORM 5
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Instructions for fiiing:
To be filed in person or by mail wfth the County AudRor of the county where the property is
located during the 12 months before May 11 of the year the dedudion is to be effective. See
reverse side for additional insWdions and qualifications. ��BSO(v CCU?1TY AUDITOR
Applip t(o �orco t2ct buy see tionsp vers si e) . i„ „,_
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Ta�cing Dis 'd Key number / legal descripf Record number
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Assessed val of real property as of Mortgage / Contrec[ indebtedness unpaid as of Is the appiipnt the sole le al or equitable
March 1, wrrent year March 1, current year ownef? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is difterent than that of applicant, indicate below:
e of moAgagee or contrad seller
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Address of moRgagee or contrad setler (number and street, ty, state, ZIP -
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, ary, state; ZIP code) •
Does applipnt own real property in any If yes, what county? What Taxing DisUid? Has this dedudion been requested on
ather county in Indiana? property for wrrent yeaf? � YesD No
COUNTY AUDITOR
Dedudion approved in the amount of:
20 �q��' �O 20 � 20 20 � 20 20 Q7 20 �_ �
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Sig ture County Auditor Date
�I e ceRify under the penalty of perjury that the above and foregoing infortnation is true and corted and that the applicants was / were
ident of Indiana and owner of the aforementioned property on March 1, 20
Signature .bw � rs full nam Person authorized by duly executed Power of Attomey
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/ Of by IC 6-1.1-12-.07
Ful resident address o applicant / / �� Address of author¢ed person _
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