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FORM 5
STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Filing fee St.00
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
State Form 43709 (R / 12-99)
Prescnhed by State Boartl of Tax Commissioners ����
File Mark
Insvuctions for filing: �AN `Z 3 2���
To be filed in person or by mail witn the County Auditor of the county where the prope
located during the 12 months before May 11 of the year lhe dedudion is to be effecliv See
reverse side for additional instructions and qualifications. GIBSON COUN7Y AUDITOR
Applicant ( ner or contract buye� ; see restn�ns n reveQ rse, side)
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Taxing Distrid Key number / legal description Record number
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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, current year March 1, current year � owneR ❑ Yes ❑ No
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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 different than that of applicanl, indicate below:
�ame of mortgagee or contract� er �
1
Address of mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicani 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 yeaR ❑ Yes� No
PROPERTY TAX ASSESSMENT BOARD OF APPEALS
Deduction approved in the amount of:
20�_ 20�i-03 20 3-ay 20O 20 200� 20_F)�
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Signature O°J Seaetary of PTABOA Date
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I/ We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
� r sident of Indiana and owner of the aforementioned property on March 1, 20
i atu wners full na ) Person authorized by duly executed Power of Attomey
� or by IC 6-1.1-12-.07
ull r' nt address of app icant Address of authorized person
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