HomeMy WebLinkAboutMortgage_Smith (30)STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
- FOR DEDUCTION FROM ASSESSED VALUATION
� � State Fam 43�09 (R3 / 1 O-00)
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.� Presuibetl �y State Boartl of Ta[ Convnissiorers
Instructions for fiiing:
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 dedudion is ro be effedive. See
reverse side for additional insUuctions and qualfiptions.
FORM 5
AUG 0 9 2001
CB=L'.`d�,TY AUDITOR
ApplipM (owne con� see restnctions on reverse si )
Taxing Distrid Key number / legal description Record nu r
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, current year March 1, current year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate Hrith whom.
If name on record is different than that of applicant, indicate below:
�e of mortgagee or contrad seller
Addre s of moRgagee or contrad seller (number and stieet city, state, ZIP .
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, aty, state, ZIP code)
Does applipnt own real property in any If yes, what counry? What Taxing Distrid? Has this dedudion been requested on
other county in Indiana? properry for current yeaR � Yes� No
COUNTY AUDITOR
Deduction approved in the amount af:
20 }L'� ' 20 20 20 a� 20 � 20 /9 % 20 �� �
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Sign Wre CountyAud'Ror Date
I/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
ident of Indiana and owner of the atorementioned property on March 1, 20
Signature (owners lull name) Person authorized by duly executed Power of Attomey
or by IC fr1.1-12-.07
Ful residen address of appliqnt Address of author¢ed person
311 �. ' '
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