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Mortgage_Mills na STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year FOR DEDUCTION FROM ASSESSED VALUATION �- + State Form 43709(R12/6-14) "�„1 Prescribed by Department of Local Government Finance :� . INSTRUCTIONS: j File O; To be filed in person or by mail. Form i th: Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. !r��7 Must be filed or postmarked with the County Auditor or County Recorder of the county where the propert9,S 1 ' g5ounty Auditor 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 m y where the property is located during the twelve(12)months before March 31 of each year the deduction ' -q,•If _� ;�-- See reverse side for additional instructions and qualifications. 9 nn. . Applicant(owner or contract buyer-see restrictions on reverse side) R1gg©� COUNTY AUDITOR Dennis A. Mills and Andrea R. Mills Taxing District Key number/legal description Reyerp number Page,nym r Owensville Township 26-17-12-204-000.466-022 Q/Q I `� [�11 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? 75700.00 68000.00 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 ❑ Real Property ❑ Annually Assessed Mobile Home(IC 6-1.1-7) Name of mortgagee or contract seller Fifth Third Mortgage Company Address of mortgagee or contract seller(number and street,city,state,and ZIP code) 5001 Kingsley Drive, MD: 1 MOCBAB, 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 ny If yes.what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction other county on property for in Indiana? Yes No current year? ❑ El 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 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 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. Sig ture nets rultname) ( DD Date(month,day,year try/. r. G,(i !/dcL� n_firlhr ho-r- Full resident address of applicant(number and street,city,state,and ZIP code) 307 S. Mill Street, Owensville, IN 47665 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.