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, STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
Y--: i FOR DEDUCTION FROM ASSESSED VALUATION
'> > State Form a3709 (R I 12-99)
�� Prescnbed by SWte BoaM ol Tax Commissioners
InsVuctions for filing:
To be filed in person or by mail with lhe Counry 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 side for additional instructions and qualifications.
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Taxing
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resMctions on reverse
number /
FORM 5
APR U � 2001
Record number
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Assessed value of real property as of Mortgage / Contrad ihdebtedness unpaid as of Is the applicanl 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 exacl share of interest? if owned with someone oiher than spouse, indicate with whom.
If name on record is different than that of appficanl, indicate beiow:
�ame of moAgagee or contrad seller
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Address of mortgagee or contracl seller (number a d street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and stieet, city, sfate, ZIP
Does applicant own real property in any If yes, what county? What Taxing Districl? Has this deduction been requested on
other county in Indiana? propeRy for current yea(? ❑ Yes❑ No
PROPERTY TAX ASSESSMENT BOARD OF APPEALS
amount of:
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>ignature Seaelary of PTABOA Date
I/ We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
resident of Indiana and owner ot the aforementioned property on March 1, 20
iignature (owners full name) • Person authorized by duly executed Power of Attomey I
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lent address of appiicant . Address of authorized person
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