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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
e_. se FOR DEDUCTION FROM ASSESSED VALUATION
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• State Form 43709(R12/6-14)
Oi Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail. Form Red 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 property is ❑. County Auditor
located on or before January 5 of the immediately succeeding calendar year. ! Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must tile with the County Auditor of thguyur
where the property is located during the twelve(12/months before March 31 of each year the deductio I so h t !
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
CARMEN HURLEY AUG 21 2015
Taxing District Key number/legal description Record number P.•r-n
JOHNSON TOWNSHIP 26-23-13-400-001.680-024 4.I( ,
Ce
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness un. ;'t1 - ��: ' plicant the sole
March 1,current year March 1,current year date of application GIBSON COU ,tanteoitt3F 'en
• $ 87,755.00 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
MI Real Property ❑ Annually Assessed
• Mobile Home(1C 6-1.1-7)
Name of mortgagee or contract seller
ACCEPTANCE CAPITAL MORTGAGE CORPORATION
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
101 PLAZA EAST BLVD., SUITE 103, EVANSVILLE, INDIANA 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? Vxhat 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 0 N
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 t 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 I contract buyer of the aforementioned property on date application is tiled.
ign t r�(owneYei( Date(month.day,year)
I\ 1 \\Vd1\"Y�' 07/ 3 ) /2015
•
ull resident address of applicant(number and street,city,state, 27P code)
• 5242 E. 1300 S, Evansville, Indiana 725
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$10,000.