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, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
7i--: : FOR DEDUCTION FROM ASSESSED VALUATION
S � State Form 43709 (R / 12-99)
,a•
� Prescribed by State Board ot Tax Commissio�ers
Instructions for filing:
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 dedudion is to be effedive. See
reverse side for additional instructions and qualifications.
Applicant
Taxing Distrid
6uyer-see
� `� -
Assessed vaiue of real pr� opeRy as of
March 1, current year
If no, what is his / her exact share of interest?
reverse
Key number / legal
FORM 5
FEB 21 2001
GIBSON COUNTY AU�
number
Q/ / � �D � ��rQ/ \ Page number �
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MoRgage / Contract ihdebtedness unpaid as of Is lhe applicanl the sole legal or e
March 1, current year owneR ❑ Yes ❑ No
� 8,� I
If owned with someone other than spouse, indicate with whom.
name on record is different than that of applicant, indicate below:
,ame of mortgagee or contrad seiler � I�
�
Address of mortgagee or contract seller (number and streef, city, state, ZIP
of assignee or other owner or holder of mortgage
Address
and st2et, city, state, ZIP code)
Does applicant own real property in any If yes, whaf county? What Tauing District? Has this deduction been requested on
other county in Indiana? property for current yeaR ❑ Yes ❑ No
PROPERTY TAX ASSESSMENT BOARD OF APPEALS
amounl of:
20 � 20 Qt�_
-.5 �,�13-b1 /��aA-
Signature
�
�'U 20�� 20�
(01 o PT"A-Bc) /
_ Secretary of PTABOA
20 �� 20 � Q i
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' We certiiy under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
name) �
, 6_ ��, _
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person