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A��_ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
/.a_ n�\\ FOR DEDUCTION FROM ASSESSED VALUATION
' State Forth 43709(R12/614) I `
Prescribed by Department of Local Government Finance I i,:
INSTRUCTIONS:
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To be filed in person or by mail. - Fq(�yi�d with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. OCT 1 i• IJ
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is LI County Auditor
located on or before January 5 of the immediately succeeding calendar year. /•I a. y Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the co 91, •�itns
where the property is located during the hvelve(12)months before March 31 of each year the deduction is •I,
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR
Applicant(owner or contract buyer-see restrictions on reverse side)
David M O'Dowd and Andrea R O'Dowd
Taxing District Key number/legal description Re nu ber Pa e n
Columbia 26-14-19-102-000.185-007 015 g�-39[n
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?
67,346.00 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
p Real Property ❑ Annually Assessed
Mobile Home(IC 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, 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 , property for
in Indiana? Yes 0 No• current year? ❑Yes 0 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/We certify under the penalty of perjury that the above and fors.oing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on dat- .pplication is filed.
`Si tore owner' full name) • AL—IL n D �1p,rJ-y,ye
ful resident address of applicant(number and s city,state,and ZIP code)
(/f/ (/
618 Walnut Street, Oakland City, IN 47660
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)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.