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, STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
-- !: FOR DEDUCTION FROM ASSESSED VALUATION
•� 2� State Form 43709 (R / 12-99)
.
`�� � Prescnbed by State Board of Tax Commissioners
Instructions for filing:
To be filed in person or by mail with the Counry Auditor of the county where the property is
located during the 12 months before May 11 of the year the deduction is to be effective. See
reverse side for additional instruclions and qualificaiions.
Applicant (owner or contract buyer
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Taxing District
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Assessed value of real property as of
March 1, current year
2strictions on reverse side)
If no, what is his / her exact share of interest?
Key number / Iegai description
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Mortgage ! Contred ii
March 1, current year
If name on record is differenl lhan that of applicant, indicate below:
If
''3me of mortgagee or contract seller
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Address of mortgagee or contrad eiler (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
of assignee (numberand street, city, state, ZIP
FORM 5
Filing fee 51.00
Coun Township Year
File Mark
(11� \D
\AJ • •
number
Page number
2z�
a��
unpaid as of I Is the applicant the sole legal or
owne�? es ❑ No
�ith someone other than spouse, indicate with whom.
Does applicanl 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 yeaRO Yes❑ No
� O
PROPERTY TAX ASSESSMENT BOARD OF APPEALS
approved in the amount of:
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Signatur�e�,�
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20 0 � 20
ry�, f�Y"figo
Secretary of PTABOA
20
Date
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/ We ceAify under the penalty oi perjury that the above and foregoing information is true and corred and Ihat Ihe applicants was / were
resident of Indiana and owner of the aforementioned property on March t, 20
(owners full
D— /-�
Person authorized by duly executed
or by IC 6-1.1-12-.07
of authorized person