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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (R3 / 10-00)
PreSqibeC M State Baartl o17ax Comnissiorers
Instructionsforfiling:
To be filed in person or by mail with the County Auditor of the county where the property is
located during tFie 12 months before May 11 of the year the dedudion is to be effedive. Se�����9���
reverse side for additional instructions arM qualfiptions. __`�� ��
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FORM 5
OCT 3 0 2001
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Ap i' n(o erorcont uyer- stn ' son" v e' e)_ � _ '
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T g Dishid number / legal description Record number /(�
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Assessed value of real prope as of Mortgage / Contrad indebtedness unpaid as of Is the applicanl the.sole legal or equitable
March 1, current year March 1, rrent year �� � g 59 q owneR ❑ 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 d'rfferent than that of applicant, indicate below:
of moAgagee or contrad seller
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Address of mortgagee or contract seller (number and stre city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, pty, state, ZIP code) •
Does applicant own real property in any If yes, what county? What Taxing Distrid? Has this dedudion been requested on
other county in Indiana? property for wrrent yeaR � Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
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zo 0 2o Zo � zo 0 5 zo G<c Zo Zo o� o
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Signature County Auditor Date
I� e certify under the penalty of peryury that the above and foregoing infortnation is We and corred and that the applicants was / were
ident of Indiana and owner of the aforementioned property on March 1, 20
igna wne/s lull name Person authorized by duly exewted Power of Attomey
�` ar by IC 6-1.1-12-.07
ull esident addr of ap lipnt � Address of author¢ed person
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