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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
• '1. State Form 43709(R12/6-14) 11 r
Presented by Department of Local Government Finance ';aril� - I.`
4.
INSTRUCTIONS: - - - - - - - - • - File Mark
To be filed in person or by marl.
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 property is ❑ County/itddor
located on or before January 5 of the hmmedratery succeeding calendar year
■ ( . ._:_ . _...-r
2) Mobae/Manufactured Homes not assessed as Real Property Must tae with the CountyAudtor oftdh1gcounty 'Cis/�.gr)►n1i
where the property is located during the twelve(12)months bete Mandl 31 of each year the deductidp�x a NTY
See reverse side for additional instructions and qualifications. AUDITOR
Applicant(ownecor coned buyer-see resux5au on reverse side)
JESSICA LYNN ALTGILBERS
Tatting Distrsd Key number/legal desorption Reclud number Page number
PATOKA TOWNSHIP 26-12-08-301-001.781-028 Qt AIaLP
Asarzsed value of real property as of Mortgage I Contact indebtedness unpaid as of Manage h Contact s,oetmdness unpaid riot leIs gal tee or equitable Mann 1,anent year Macon 1,anent year date of application legal or equitable owner?
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$ 54,883.00 D Yes ❑ No
II no,what is his/her exact snare of retest? If owned with someone other than spouse.innate with whom
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I name on record is deferent than that of applicant,indicate before. Is the property b question;Annually Assessed
m Real Property ❑ An nla!y Assessed
Name of mortgagee or contract sego Mobile Home(IC 61.1.7)
ACCEPTANCE CAPITAL MORTGAGE CORPORATION
Address of mortgagee or contract seller(number end net sly,stare.and ZIP Door)
101 PLAZA EAST BLVD., SUITE 103, EVANSVILLE, INDIANA 47715
Named assignee or oter owner or kidder of mortgage
Address of assignee(number and street ray,state,and ZIP code). .
Does appinM own property in any If yes,what county? Mat Taxing District? 'Has this deduction been
other county ❑Yes ❑No on property for requested ,t yes,state amount of daductbn
In Indiana? raiment year? ❑Vas El NO
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contact indebtedness that is recorded in the county
recorder's office(rndudmg any home equity fine of credit that is recorded in the county recorder's office)that As the basis for the deduction.
• COUNTY AUDITOR
Deduction approved in the artuamt on
20 20 20 20 20 20 20
Signature of County Auditor County Date(moth,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 In&ana and
comer/contract buyer of the aforementioned property on date application is filed.
Si/nature(owners M name) Date(month.day,year)
ik
J2/N^-NA-en- ) � n * \o2t 06/ tic /2015 .
ull resident addrsss of applicant( and street city. ,and ZIP rode)
1106 E. EVANS STREET, PRINCETON, INDIANA 47670
Person authorized by duly...nomad Power of Attorney or by IC 6-1.1.12-0.7
Data(motor,day,year)
Address of authorized person (number end street Ply,sate,and ZIP code)
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The penalties for perjury can include imprisonment up to caw end a half years and a fine not to exceed$70,000.
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