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STATEMENT OF MORTGAGE OR CONTRACT
INDEBTEDNESS�FOR DEDUCTION FROI�A ASSESSED
VALUATION State Form 43709 (1-90) Prescribed by the
State Board of Tax Commissioners
Instructions 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 reverse for additional instructions and qualifications.
FORM 5
.�FsFI4R ;fee.,_$1-.00
Coun ` T�iwns�i '� Year
«..,....'.:.�:-- .
( Y i 0 2000
F{le KiYark
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•' u1BSON G•�UNTY 0.U71TOR. _
Applicant (Ow r or contract � e restrictions on reverse) � •
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Taxing Distri t• Key Number/Legal Description Record o. "
� — � ,� - O . Page No. .
Assessed value of real property as Mortgage/Contract Indebtedness unpaid Is the applicant the sole legal'or
of-March 1, current year as of y1a�h 1, current year. ' - equitable owner? O yes' O no
9.-f
If no. what is his/he� exact share or interest? � If owned with someone other than spouse,
indicate with whom.
If name on record is different than that ofapplicant, indicate below:. . .
�"' -�e.of mortgagee or contract seller �
�- , . . _
Address of mortgagee or contract seller' • _ -
Name of Assignee or other owner or holder ortgage.
Address of Assignee �
Does applicant own real property If yes, what county? What Taxing District? Has this deduction been
in any other county in Indiana? requested on property for current
year? O yes ❑ no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
Year � Yea�60� Year � Y ar � Year 6 Year � S Year
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Signature Secretary of Board of Review Date
aoo7_P 2�SU&Q aoo9 �
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the
�licants was/were a resident of Indiana and owner of the aforementioned property on March 1,
re (owners full name) Person authorized by duly executed Power of Attorney or
� by IC 6-1.1-12-.07).
Full esiden ddress of Applicant Address of Authorized Person
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