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. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count I `!To1 ;�l�
Si S FOR DEDUCTION FROM ASSESSED VALUATION
lt� State Form 43709(R12/6-13) GibsoNQ 2015
"-- •' Prescribed by Department of Local Government Finance !
INSTRUCTIONS: File Mark
To be filed in person or by mail. (:�°�' 1 , • x M. -- nth:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction isRRW eeNCnII rerl'f1:
Must be filed or postmarked with the County Auditor or County Recorder of the county where the propefyl5`IN ,Nita Counptty Auditor
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located on or before January 5 of the immediately succeeding calendar year. • Co�nry Recorder
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.
Appficam(owner or contract buyer-see restrictions on reverse side)
Dustin L. Howell
Taxing District Key number/legal description R d qum��/ F
Patoka 26-11-15-101-004.237-027 0 I o
Assessed value d real property as d Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness u as of Is the applicant tiie sole March 1,current year March 1,current year date of application legal or equitable owner?
219,600 169,600 p 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
El Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Mortgage Masters of Indiana, Inc.
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
7144 E. Virginia St. Evansville, IN 47715
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 on 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 credit that is recorded in the county recorder's office)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 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/ ntract buyer of the afore ntion operty on date application is filed.
Signature < eras ru name) Date(month,tl1y, 1
11/21//2014
Full resi ent address of applicant( mber and et,city,state,and ZIP code)
2689 W. Julie Dr. Princeton, IN 47670
Person authorized by duly executed Power of Anomey 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$10,000.