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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sfate Form 43709 (R / 12-99)
Prescri�ed by State Board ol Tax Commissioners
InsGuctians 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.
contract 6uyer- see restrictions on reverse side)
FORM 5
number / legal description I Record
MAY 10 2001
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Assessed vatue of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, cufrent year � owner? ❑ Yes ❑ No
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If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicale with whom.
If name on record is different than that of applicant, indicate below:
of moRgagee or contrad seller
Address of mortgagee or contrad seller (number and stieet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own real properly in any If yes, what county? What Taxing Districl? Has this deduction been requested on
other county in Indiana? property for currenl yeaR ❑ YesO No
PROPERTY TAX ASSESSMENT BOARD OF APPEALS
Deduction approved in lhe amount of:
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Signature
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Date
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We certify under the penalty of perjury lhat the above and foregoing information is true and corred and that Ihe applicants was / were
resident of Indiana and owner of lhe a(oremenlioned property on March 1, 20
(owners /ull name)
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full resid-ent address of applicant — �Address of authorized person