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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE�"
FOR DEDUCTION FROM ASSESSED VALUATION
State Form a37a9 (R / 12-99)
Prescribed by State Board of Ta�c Commissioners
FORM 5
— File Mark
200�
Instructionsforfiling: APR �6
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 the year the dedudion is to be effedive. See
reverse side for additional instruclions and qualifications. G�gSON COUNTY AUDITOR
buyer - se� je�trictions on reverse
Taxing
Assessed value of real property as of
March 1, cunent year
If no, what is his / her exacl
ofinterest?
Key number / legal description
Record number QI
('��)`� ������ Q�\ I Page number n��
�J lJ Q/
Mortgage / Contract indebtedness unpaid as of Is ihe applicant the sole legal or eqwtable
March 1, current year owneR ❑ Yes ❑ No
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If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
iame of mortgagee o wntract seller � L� ./�
V
Address of mortgagee or contracl seller (number and stieet, city, state, ZIP
or other owner or holder of mortgage
of assignee (number and street, city, state, ZIP code)
Does applicant own real property in any If yes, what county? What Taxing District? Has this dedudion been requested on
other county in indiana? property for current yeaf� ❑ Yes� No
PROPERTY TAX ASSESSMENT BOARD OF APPEALS
Deduction approved in lhe amount
20 �_
.Il�b�
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20 �� 20 � 20
Secretary of PTABOA
20 �� � 20 D
/ We certify undEr the penalty of perjury Ihal lhe above and foregoing informalion is true and correIX and that the applicants was / were
, resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duiy executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person
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