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/M�\ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count ? f �!+ r
i FOR DEDUCTION FROM ASSESSED VALUATION ; •iQ'�t `�
State Form 43709(R11/6-09)
Prescnbed by Department of Local Government Finance L.Ilex gg
I r
INSTRUCTIONS:
To be filed in person or by mail. Fo tiled with'
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought.
Must be filed with the County Auditor or County Recorder of the county where the property is located p��it toR
on or before January 5 of the immediately succeeding calendar year. GIBSDN 9U�ll yItgLer
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the
county where the property is located during the twelve(12)months before March 31 of each year the
deduction is sought.
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Randal J.&Jessi K Meeks,husband and wife
Taxing District , Key number/legal description Record number Page DOtef when
LL1 XOLL-i) 26-19-18-203-001.874-025/Lot 38&S 1/2 Lot 35 Sunrise Acres Sec A 2001300001744
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current year date of application legal or equitable owner?
200000.00 0 Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
0 Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Old National Bank
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
One Main Street Evansville IN 47708 •
4.1a Qsr/
Name of assignee or other owner or holder of mortgage A,,, , f/ 0-%✓•
Address of assignee(number and street,city,state,and ZIP code) / /
Does applicant own property in any other If yes.what county?. What Taxing District? Has this deduction been requested on property
county in Indiana? for current year?
❑ Yes Fl No ❑ yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor County Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Sign tar (ow ers{tall nom ) Date(month,tlay.year)
/� 1,, 03/29/13
Full resident add ss of applicant(number and street,city,state,and ZIP code)
194 E.750 S.Ft Branch IN 47648
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street.city,state.and ZIP code) `'\