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FORM 5
STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
Siate Form 43709 (R3l 10-00) ���,'� �.j9 1
Presaibe0 Oy State Boartl ot Tax Comrttissioners FI '� � I
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r5ry s � 200
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InsUuctions for filing:
To be filed in person or by mail with the Counry Audftor of the couMy where the property is���""'_ "
located during the 12 months before May 11 of the year the deduction is to be effective. See G!BSON COU1 � Y AUDITOR I
reverse side for additional insWctions and qualifications.
P,pplipnt (ownerorcon buyer- see 2strtctions on reve e side)
Taxing Distrid Key number / legal descri n Record number
� /�, �� Page number �
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Assessed value of real property as of Mortgage / Contre indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, current year � O O Q ownef? ❑ Yes ❑ No
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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 of applicant, indicate below:
of mortgagee or contrad seller
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Address of mortgagee or conVact seller (number an street, city, state, ZIP ..
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Name of assignee or other owner or holder of mortgage �
Address of assignee (numbe� and street, dty, state, ZIP code)
Does applicant own real property in any If yes, what county? Whal Taxing Distrid? Has this dedudion been requested on
other county in Indiana? property for wrrent yeaR � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �- 03 zo 0 zo ��j[ 20 0 20 � zo a7 zo Q$_ a 9
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Signature County Audkor Date
�Ne certify under the penalty of perjury that the above and foregoing infortnatlon is We and cortect and lhal the applicants was / were
ident of Indiana and owner of the aforementioned property.on March 1, 20
Si ature (owner's ll name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
ull r ident ad ss of app i t Address of author¢ed person
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