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/k STATEMENT
EDUC IO MORTGAGE S CONTRACT INDEBTEDNESS De hip I Year
r � FOR DEDUCTION FROM ASSESSED VALUATION
6• 1 State Form 43709 R12 I 6-14 ibso u is t
Prescribed by Department of Local Government Finance
INSTRUCTIONS:
FEB 1 2 Mark
To be filed in person or by mail. •w fled with:
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought.
Must be filed or postmarked with the County Auditor or County Recorder of the county where the prop is, n n Cou ty Auditor
located on or before January 5 of the immediately succeeding calendar year. �j County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property Must file with the County Auf tr^( s y,QT ,
where the properly is located during the twelve(12)months before March 31 of each year the deduction is W! - 2 I '
See reverse side for additional instructions and qualifications.
Applicant(owner or contact buyer-see restrictions on reverse side)
Matthew A. Moran and Shannon M. Morgan
Taxing District Key number/legal description Rnum Pane nn Haubstadt 26-22-01-200-000.001-009 edn /R u
Assessed wake of real property as of Mortgage I 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?
150,400.00 ten 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 racord is different than that of applicant indicate below: Is the properly in question:Annually Assessed
Vj Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contact seller
Fifth Third Mortgage Company
Address of mortgagee or contract seller(number and street,coy stare.and ZIP code)
5001 Kingsley Dr, 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 ,,/y��� on property for
in Indiana?. Yes XN° 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 I 20 20 20 20 I 20 20
Signature of County Auditor I 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 hill namel I Daze(month.day,year)
z-6• Is
Full resident dress apNi a (nu a street,city.state,and ZIP code)
417 !N. W st St., ub adt, IN 47639
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 I Date(month,day.year)
Address of authorized person (number and steer 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