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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION i
♦ � Sfate Fortn 43709 (R3 / 10.00)
� PreSaibeA M Sfate BoarE of Ta: Conv�tissiorers
Instructions for filing:
To be filed in person or by mail with the County Auditor of the county where the praperty is
located during the 12 months before May 11 of the year the dedudion is to be effedive. See
reverse side for additional insWctions and qualfications.
Taxing Dishid
see
�V �.�.�- P.�,,u'e.�+
Assessed value of reat property as of
March 1, current year
If no, what is his / her exad share of interest?
on
number / legal
FORM 5
JUL 0 9 2001
GIBSON
number
� O - QO � �_� Page number- � �.
Mortgage / Contrad indebtedness unpaid as of Is the appliqnt the sole legal or
March 7 current year owneR ❑ Yes ❑ No
.3�, csbb
If name on record is difFerent than that of applicant, indicate below:
or cantrad seller
If owned with someone other than spouse, indicate with whom.
Address ot mortgagee ar 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 applipnt own real property in any If yes, what county? What Taxing Distrid?
other county in Indiana?
COUNTY AUDITOR
approved in the amount
20 I�j�����° I 20
)
20
Caunty Auditor
�
Has this dedudion been requested on
property for current yeaR ❑ Yes ❑ No
20
Date
20
ceRify under the penalty of perjury lhal the above and foregoing infortnation is We and correct and Ihat the appiicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
ire (o}v/�er�� 1 n�e) n �J Person authorized by duly executed Power of Attomey
�� x%,� or by IC 61.1-12-.07
Address of author¢ed person
�40