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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
♦ � State Fortn 13709 (R3 / 10-00)
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,� Presaibed M Stele Board of Tax Cortmussioners
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Instructions for filing:
To be filed in person or by mail with the County AudRor ot the county where the property is
located during the 72 months before May 17 of the year the dedudion is to be eBective. See
FORM 5
Coun Township Year
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SEP 18 2001
reverse side for additional instrudions and qualfications. /�
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Applipnt (owneror ct buyer- see 2stnctio on rse si ) - "� "� ' •�
Taxing Distrid Key number / legal description Record number QD
J�/�1 � O J([� O—�� Page number ��i j�Q
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Assessed value of real propeRy as of Mortgage / Contract indebtedness unpaid as of Is the applipnl the sole legal or equitable
March 1, current year March 1�rrent year_ owneR ❑ Yes ❑ No �
c� 1 0 0�
If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that af applicant, indicate below:
� of mortgagee ntrad seller ��
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Address of moRgagee or contrad seller (number and street, city, state,•ZI � .
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Name of assignee or other owner or holder of mortgage
Address of assignee (number and sUeet, dry, state, ZIP code) • -
Does applipnt own real property in any If yes, what caunty? What Taxing Distrid? Has this dedudion been requested on
other county in Indiana? property for current yeaf? ❑ Yes� No
COUNTY AUDITOR
Deduction appraved in the amount of:
20 -��, 2 20 20 _Q,� 20 20 � 20 �
5 � �
Sig ture 0 9 County Auditor Date
I
e ceRify under the penalty of perjury that the above and foregoing information is true and corced and that the applicants was / were
ident of Indiana and owner of the aforementioned propeAy on March 1, 20
Signature (owners Iull name) Person authorized by dury executed Power of Attomey
� or by IC 61.1-12-.07
ull resident add ss of ap lipnt Address of authorrzed person
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