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STATEMENT OF MORTGAGE OR CONTRACT
INDEBTEDNESS FOR DEDUCTION FROM ASSESSED
VALUATION State Form 43709�(1-90) Prescribed by the
State Board of Tax Commissioners
Instructions for filing:
To be filed in person.or by mail with the County Auditor of the courity where the
property is located during the 12 months before May 11 of the year the deduction
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FORM 5
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Applicant (O n r or c ntract f uyer - e•re ictions n reve � ' N�oU�yAUOiroq
Taxing District � ,"Key Number/Legal Description Record No. . b
o �U/� (L��f,—�1 (Q -�J Page No. . .
Assessed value of real property as Mortgage/Contract lndebtedness unpaid Is the applicant the sole legal or
of March 1, current year� " as of March 1, current year. � equitalile owner? O yes O no
�
If no, what is his/her 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: ,
��e of mortgagee or contract selier Q
Q
Address of mortgagee or contract seller " .
Name of Assignee or other owner or holder of Mortgage.
Address of Assignee . � . . . � - _ -
Does appticant 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? ❑ yes O no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
Year�nDl � ' a-3 Year � Year �f � Year�a °-` Year � Yeare�-%/D y
�•�r°I
Signature 1`� 0 q Secretary of Board of Review Date
1 �
I/We certify under penalty 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,
S� ature owners full r,�me � Person authorized by duly executed Power of Attorney or .
� j by IC 6-1.1-12-.07).
F e ident Address of Applicant . Address of Authorized Person