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FORM 5
STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R3 / 16-00)
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. �\�� - , � File Mark
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 moMhs before May 11 of the year the deduCion is to be effective. See
reverse side for additional instructions and qualifications.
Applipnt ( er or contract buyer- see trictions on reverse side)
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Taxing DisVid Key number / legal description Record number O I
/ . �� D — 0�� � —� � Page number
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, currenl year ' March 1, current year owneR ❑ Yes'�.No
/Z d o 0
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 diflerent than that of applicant, indicate below:
�� moAgagee or conVad seller
Ga,eO a�er�� � �l o f' /�n� ic,� �
Address of mortgagee or contraG seller (num r and sbeet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sGeet, aty, state, ZIP code)
Does applicant own real property in any If yes, what county? What Taxing Disfid? Has this dedudion been requested on
other county in Indiana? property for wrtent yeaf? � Yes ❑ No
COUNTY AUDITOR
Dedudion approved in the amount af:
20 n 1_ 20 20 20 ,�'i 20 o G 20 O 20 �_
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Signature 09 County Auditor Date
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.�e�certify under the penalty of peryury that the above and foregoing information is Vue and corted and that the appiicants was / were
Jent of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners /u!I name) Person authorized by duy executed Power of Attomey
��, s or by IC 61.1-12-.07
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Full resident address of appliqnt Address of authorsed person
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