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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R I 12-99)
Prescribed by State Board of Tax Commissioners
FORM 5
Filing fee 51.00
Coun Township Year
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F t�jFile�1���
InsVuctions 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 effective. See C�B/�NTY AUDITOR
reverse side for additional instructions and qualifications.
Taxing
Assessed value of real property as of
March 1, current year
If no, what is his / her exact share of interest?
on reverse
Key number / legal description Record number O/
0/9 - 0/GiG -o� Pagenumber ���
Mortgage / Contrad fndebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year � owne(? ❑ Yes ❑ No
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/ If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
^�lame of mortgagee or contrad seller
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Address of moRgagee or wntract seller (number and st �t�city, state, ZIP
of assignee or other owner or holder of mortgage
of assignee (numberand street, 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 yea(? ❑ Yes❑ No
PROPERTY TAX ASSESSMENT BOARD OF APPEALS
Deduction approved in the amount of:
20 _�
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PO �� �'�� 20
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20� 20� 20
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Signature i� h q 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 corred and that the applicants was / were
'resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
FullYesident address of appl��.ant Address of authorized person
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