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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R71 / 6-09)
Prescnbetl by Department of Local Govemment Finance
Count Township Year
Gibson Patoka 2073
File Mark
�RUCTIONS:
�led in person or by mail. Fortn ed �u
ig Dates: 7J Real Property: Must be completed and dated in the calendar yearlor which the deduction is sou t. quditor
Must be lled wifh fhe CountyAuditor or County Recorder of the crounry wbere the property is located
on or before January 5 of the immediately succeeding calendar year. Counry Recorder
2) Mobile / Manufactured Homes not assessed as Real Property: Must file with the CountyAudifor of the � U L
county where the property is located during the M1velve (72) months before March 37 of each year the
deduction is soughL C ��
See reverse side /o� additional instructions and quali�cations.
Applicant (owneror conUact bvyer see restnUions on reverse side)
Kenneth L. Klein, II and Brooke E. Klein
Taxing DisMct Key number I legal descnption
Patoka 2G12-09-103-000.172-027
GIBSON COUNTY
number � Pa9e number
0.cussetl value ot real properry as of Mortgage / Contraq inEeEtedness unpaid as of Mortgage / ConVact indebtedness unpaid as of Is ihe applicant ihe sole
March 7, current year - March 1, wrteni year date of applira[ion legal or equitable owner?
„o.soo >>s.seo o ve5 ❑ n,o
If rro, what is his I her ezact share of interest? If owned vriN someone other than spouse, indicate vrith whom
If name on record is tliRerent ihan that of applicant, indicate below Is the property in question: AnnuallyASSessed
❑� Real Property ❑ Mnually Assessed
Mobile Home tlC G1.Y7
Name of rtwrtgagee or convacl seller
Old National Bank
Address of rtwrtgagee or mntract seller (number and streef, city, sfale, and ZIP code)
1 Main Street Evansville, IN 47708
Name of assignee or oNer owner or holder of rtartgage
Address of assignee (number and sfreet, uty, stare, and ZIP code)
appliwnt avn property in any oNer If yes, what counry? VJhat Tazing Distria?
Yes LI No
Has Nis detlucUOn been requestetl on property
torwrteneyeaR
n Yes n No
COUNTYAUDITOR
Deduction approved in the artwunt oC
I20 20 20 20 20 _ 20 _ 20
SgnaN/re� ot CounryAWitor Counry Date (month, day, year)
`. � '
I/ We certify under the penal of perjury th e above and foregoing information is true and wrrect and that Ihe applicant is a resident of Indiana and
owner I wnVact buyer of the aforemeniioned property on date appliwtion is filed.
Signature (ownels lull name) Date (rtanth, day year)
� - �L � • � 07/16/2012
Full resident a dress o applicant (numb r arM streef, uty, state, and ZIP coUe)
1542 Outer Lake Rd. Princeton, IN 47670
Person authorized by duy exewted Power o/Attomey or by IC 67.142-0] Date (month, tlay, yea�
Address af auNOrized person (num6er and street. uty, state, anOZIP code)