HomeMy WebLinkAboutMortgage_Lewis (9)STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
- FOR DEDUCTION FROM ASSESSED VALUATION
t / State Fartn 43709 (R3 / 1090) .
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� PreSaibeO M SUte Boartl of Tax Cortunissiorers
InsWctions 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 betore May 11 of the year the dedudion is to be.effedive. See
reverse side for additional insWdions and qualifiptions.
FORM 5
Coun Township Year
� JUL 1 1 2001 a�
GIB�lTY AUDITOR
Applicant ( erorconhact bu er- e stric6o s on reve ns.ide)� ,, n �
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Taning Distrid Key number / legal description Recard number ' D
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, current year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned wilh someone other than spouse, indicate with whom.
If name on record is different than thal of applicant, indicate below:
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� of mortgagee or contrad seller
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Address of mortgagee or conVact selier (number and st�eet, city, state, ZI . �
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, dty. state, ZlP code) '
Does applipnt own real property in any If yes, what county? What Taxing Distrid? Has this dedudion been requested on
other county in Indiana? property for current yeaR❑ YesO No
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COUNTY AUDITOR
Deduction approved in the amount of:
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Signature (�'i�. County Auditor Date
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�I/ e ceRify under the penalty of perjury 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
Signature (owners full name) Person authorized by duly executed Power of Attomey
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Full resident address of applipnt Address of author¢ed person
SO 70 G .� . ll�v ,� • �. �"-.