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STATEMENT OF MORTGAGE OR CONTRACT INDI
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (R3 / 10-00)
Presaibe0 GY State Board of Tac Conmiissioners
Instructionsforfiling:
To be filed in person or by mail with the Counry Auditor of the couMy where the property is
located during the 12 months before May 17 of the year the dedudion is to be effective. See
reverse side for additional insWdions and qualifications.
FORM 5
SEP 12 2001
GIB��Nrv al�n��
Applicant (ow r aont buyer- see 2 ri' s o rev e si )" �/7 . . '_ '
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Taxin Distrid Key number / legal description Re d number D�
� �%C�� � �� - oaaa� � Page number
Assessed value of real property as of Mortgage / Cantred indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, wrrent year March 1 current year � owne(? ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someone other than spouse, indiqte with whom.
If name on record is d'rfferent than that of applicant, indiwte below:
�' of moRgagee or contrad seller _
Address of mortgagee or contract seller (number and st2eC city, state, ZIP
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Name of assignee or other owner or holder of mortgage �
Address of assignee (number and sbeet, dty, state, ZIP code)
Does applipnt own real property in any If yes, what county? What Taxing DisVid? Has this deduction been requested an
other county in Indiana? property for current yeaR � Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
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Signature Caunty Auditor Date
e certiy under the penalty of perjury that the above and foregoing information is We and corred and ihal the applicants was / were
- �ent of Indiana and owner of the aforemenGoned property on March 1, 20 �
Si ature wners full name) Person author¢ed by duty executed Power of Attomey
� or by IC 61.1-12-.07
Fuil resident address applicant Address of author¢ed person
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