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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form a3709 (R / 12-99j
Prescn6ed by State Board otTac Commissioners
Instructions 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 the year the deduction is to be eHective. See
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FORM 5
Fiiing fee 51.00
Coun Township Year
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MAR 05 2001
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Applicant erorcontract buyer- see strictions on reverse side) � C1os�n CQ�,yTY AUDI70R
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Taxi Di d Key number / legal description Record number O�
,/� -� Page number
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is lhe applicant the sote legal or equitable
March 1, current year March 1, current year � owne(? ❑ Yes ❑ No
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If no, what is his / her exacl share of interest? If owned with �dmeone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
�Name of mortgagee or contrad seller
Address of mortgagee or contract seller (number nd reef, city, state, ZIP
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Name of assignee or other owner or holder of mo gage
Address of assignee (number and street, city, sfate, ZIP code)
Does applicant own real propeAy in any If yes, what county? What Taxing District? Has lhis deduclion been requesled on
other wunty in Indiana? property for current yeaR � Yes� No
PROPERTY TAX ASSESSMENT BOARD OF APPEALS
Deduction approved in the amount of:
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Signature 08 (� Secretary of PTABOA Date
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I/ We certify under the penalty of perjury that the above and foregoing information is true and correct and thal the applicants was / were
� resident of Indiana and owner of the aforementioned property on March 1, 20
Jignature ners full name) Person authorized by duly executed Power of Ariomey
/ � .7,� ��..y� or by IC 6-1.1-12-.07
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Full res" nt address of applicant Address of auihorized person
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