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e� *t,,y STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
l. ". A FOR DEDUCTION FROM ASSESSED VALUATION 2015
3.\ State Form 43709(R71 16-14)
1. Prescribed by Department of Local Government Finance gek�
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.INSTRUCTIONS: gy
-To be filled in person or by mail. Form filed with:
;Piling Dates: 1)Real Property:Must be completed and dated in the calendar year for which the deduction is sought. f�
Must be filed or postmarked with the County Auditor or County Recorder of the county where the M I Y 2 8 2015 unty Auditor
properly is located on or before January 5 of the immediately succeeding calendar year. ❑ County 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 ,. i
deduction is sought. GIBSON COUNT
%See reverse side for additional instructions and qualifications. Y AUDITOR
'Applicant(owner or contract buyer-see restrictions on reverse side)
Benjamin F. Kixmiller
Taxing District Key number/legal description 26-06-06-300-002.757-017/6797 N State Record number Page number
Road 65, Hazleton, Indiana 47640
I. 26-06-06-300-002.757-017 /6-0 /13
'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?
$168,000.00 13,1,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
i- real Property ❑Annually Assessed
t / Mobile Home(IC 6-1.1-7)
i Name of mortgagee or contract seller
Evansville leathers Federal Credit Union
!Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
4401 Theatre Drive, Evansville, IN 47715
Name of assignee or other owner or holder of mortgage
I'
(Address of assignee(number and street,city, state,and ZIP code)
j
!Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of
!other county on property for deduction
lin Indiana? ❑ Yes coNo current year? ❑ Yes ❑ No
COUNTY AUDITOR
!Deduction approved in the amount of:
I 20 20 20 20 20 20 20
Signature of County Auditor County Date(month,day,year)
i
1 I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
I' owner I contract buyer of the of mentioned property on date application is filed.
lgna re(owners full carpe) fate(month,day,year)
TI\!''1Ir
`IF I resident address o pplicant(nu ber and street,city,state,and ZIP code)
16797 N State Road 65, Hazleton, IN 47640
Person authorized by duly executed Power of Attorney or by IC 61.1-12-0.7 Date(month,day,year)
!{address of authorized person(number and street,city, state,and ZIP code)
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The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed S10,000.