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t STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS CDUn jv1-�;�'ffj.{�'_
i1 FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R12/6-14) It
,r, Prescribed by Department of Local Government Finance • _
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INSTRUCTIONS: F ''4
To be filed in person or by mail. Farm filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is soiAght. ' ' i
Must be filed or postmarked with the County Auditor or County Recorder of the county where tFi 1..:4,0 1• vanyi; •uditor
located on or before January 5 of the immediately succeeding calendar year. OUN 1 „r- R rder
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)
Anthony Hammel and Jessica D. Hammel
Taxing District Key number/legal description R rd number Page number .
Francisco Twshp 26-13-20-103-000.329-005 o/OI'-1 q/011
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?
119700.00 116844.00 0 Yes ❑ No
If no,what is his I 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
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Fifth Third Mortgage Company, its successors and/or assigns
Address of mortgagee or contract sever(number and street,city,state,and ZIP code)
5001 Kingsley Drive, MD:1MOBA8, Cincinnati OH 45227
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 ❑No 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 aedit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of: f
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 full nom• // Date(month,day,year)
J(” rani s?� �.l AA` t •• II 4S.4.—....--
Full residen•add - •f a••icant(number and street,city,sate,:s•ZIP code)
401 -n er St., Francisco, IN 47649
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)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 310,000.