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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R / 72-99)
Presaibed by State Board ot Tan Commissioners
InsVUCtions for filing:
To be filed in person or by mail with the County Auditor of the county where the property is
localed during the 12 months before May 11 of the year the dedudion is to be effective. See
reverse side for additional instructions and qualifications.
contract 6yyer- see
/-�on/
Taxing Dislrict
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Assessed value of real property as of
March 1, curtent year
no, what is his / her exact share of
name on record is different than
of mortgagee or contract seller
tions on reverse si
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Key number / legal description
D/ g— 00378-00
Mortgage / Contract indebtedness unpaid as
March 1, current year
FORM 5
a MaR �' � ��U n �
G�gS�N
d number � (
number � �
Is the applicanl the sole legal or
ownef� ❑ Yes ❑ No
I00 O o O
If owned with someone other than spouse, indicate with whom.
of applicant, indicate below:
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Address of moRgagee or contract seiler (number and st2et, city, state, ZIP
of assignee or other owner or holder of mortgage
of assignee (num6erand street, city, state,
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 yeaR � Yes � No
PROPERTY TAX ASSESSMENT BOARD OF APPEALS
approved in the amount of:
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,/3_ b)
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Signature CY�2 O q � Secretary of PTABOA
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20 O��_
Date
20 D �
/ We certify under the penalty of perjury lhat the above and toregoing information is true and corred and that the applicants was / were
�tesident of Indiana and owner of ihe aforementioned property on March 1, 20
Person authorized by duly executed
or by IC 6-1.1-12-.07
esioenc aoaress or appucanc Hooress ot autnonzea person
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