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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R ! 12-99)
Prescribed by State Board ot Tax 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 deducfion is lo be effedive. See
reverse side for additional instructions and qualifications.
FORM 5
MAY 10 2001
GIB/�iTY AUDITOR
Applican w r or contrac 6Uyer- see rest ''ons on r verse side)
Tax' is ' Key number / legai descripfion Record number /
�1 � /
� /�„ b(�i� , V ' / � �� ! �—C/V Page number � ! �
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As essed value of real property as of Mortgage / Contract ihdebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year ownen ❑ Yes ❑ No
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If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than thaf of applicant, indicate below:
�me of mortgagee or contrad seller � n�
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Address of mortgagee or contracl seller (number and st2et, c, tate, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st�eet, city, state, ZIP code)
Does applicant 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 yeaf?� Yes❑ No
PROPERTY TAX ASSESSMENT BOARD OF APPEALS
Deduction approved in the amount of:
20 � 20 20 �I� 20 f� 20 �� 20. 20 �Z
ts 4-1�-�� (,- I$- a2 � J� {'
Signature �� O R Seuetary of PTABOA Date
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I/ We certify under the penalty of perjury lhat the above and foregoing information is true and correcl and that the applicants was / were
esidPr,l of Indiana and owner of ihe aforementioned property on March 1, 20
� Signature (owners full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person