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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES"
FOR DEDUCTION FROM ASSESSED VALUATION
Stale Form 43709 (R / 72-99)
PrescnDed by State BoarO o1 Tax Commissioners
InsVuctions 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 lhe year the deduction is to be effective. See
reverse side for additional instructions and qualifications.
FORM 5
buye� - se� rey5tqctioy� on r�verse side)
APR 2 3 2001
/ legal description I Record number D f�
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Q� _O�� 3�^—� Page number � / O Qa,'
f'iV (7 �.J
Assesse value of r I property a of Mortgage / Contrad indebtedness munpaid as of Is the applicanl the sole legal or equitable
March 1, current year March 1, cuF}�+t year ly V� x J(7� ownef? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? owned with someone other than spouse, indicate with whom.
If name on record is different than lhat of applicanf, indicale below:
of mort9agee or conlrad seller
Address of mortgagee or contract seller (number and street,
Name of assignee or other owner or holder of mortgage
Address of assignee (numbe� and st2et, city, state, ZIP code)
slate, ZIP
Does applicant own real propeRy in any If yes, what county? What Taxing District? Has lhis deduclion been requested on
oiher county in Indiana? property for current yeaR � Yes ❑ No
PROPERTY TAX ASSESSMENT BOARD OF APPEALS
Deduction approved in the amount
20 �_ 20b� _ ° �
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20 �� •ey I 20
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Signature �� � Secretary of PTABOA
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20
20 �
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Date
20
I/ We certi(y under ihe penalty of perjury that the above and foregoing information is true and corred and that lhe applicants was / were
� resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
� or by IC 6-1.1-12-.07
person