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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R / 12-99)
PrescnDeC by Stale Board o1 Tax Commissioners
InsVuctions for filing:
To be filed in person or by mail with the County Auditor of the counry where the property is
located during the 12 months before May 11 of the year the deduction is to be effective. See
reverse side for additional instructions and qualifications.
Applicant (owner or contract buyer- see
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Taxing District
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Assessed value of real property as of
March 1, current year
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no, what is his / her exacl share of inlerest?
on reverse side)
FORM 5
Fiiing fee 51.00
Coun Township Year
File Mark
MAY 10 20U1
GiBSO� CW.'::': .SUDlTOR
Key n m er / legal description Record number �
' Page number
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Mortgage / Contrad indebtedness unpaid as of Is the applicanl the e legal or e
March 1, current year owneR es ❑ No
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If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
�ame of mortgagee or� rt s�ll� �
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Address of moAgagee or contract seller (number an street, c'ty, state,
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Name of assignee or other owner or holder of mortgage
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Address of assignee (number and street, city, state, ZIP code)
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Does applicant own real property in any If yes, what county? What Taxing District? Has this deduction been requested on
other county in Indiana? property for current yeaf? ❑ YesO No
PROPERTY TAX ASSESSMENT BOARD OF APPEALS
Deduction approved in the amount
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iignature Secretary of PTABOA Date
I/ We certify under the penalty of perjury that lhe above and foregoing information is true and corred and that the applicants was / were
1 resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by
or by IC 6-1.1-12-.07
person
of Attomey