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^x>o STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count Township Year
3",;e-_-_;t ¢ FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R12(6-14)
•S on. 4 Prescribed by Department of Local Government Finance
INSTRUCTIONS: AFile Mark
To be filed in person or by mail. MU .. e: ; r'.
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought.
Must be riled or postmarked with the County Auditor or County Recorder of the county where the property is ❑ Cowl Auditor
located on or before January 5 of the immediately succeeding calendar year , : .7-4417:471%
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of th n�t Recorder
where the property is located during the twelve(12)months before March 31 of each year the deductio M C I: • - - • i • -
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Schlacks, Elizabeth, N.
Taring District Key number/legal description RV ry I _ Psep ntgr
26-14-18-403-001-283-007
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 f application 1 legal or equitable owner?
S5 N 4'0 • LA) V) 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
151 Real Property ❑ Annualy Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
German American Bancorp
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
711 Main Street, Jasper, IN 47547
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county , property for
in Indiana? Yes current year? ❑Yes No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's oyce)that is the basis for the deduction.
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.
Signature(owner's fun name) Date(month,day,year)
P11 , , ��c �cY2� 2j -/ lc/
Full reside t dress of applicant(number and street,city,state,and ZIP code)
231- East Columbia St., Oakland City, IN 47660
Person authorized by duly executed Power of Attomey 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)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 810,000.