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STATEMENT MORTGAGE CONTRACT INDEBTEDNESS Coun � Township i �
wYear
' FOR DEDUCTION FROM ASSES SED VALUATION
i State Form 43709(R72/frith) Gibso B n
Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: 1
To be filed in person or by mail. `IAN r•tm b43 I'. :
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 ❑ Cou ty Auditor
located on or before January 5 of the immediately succeeding calendar year. I. . -,: Rrr C ty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property Must file with the County Auditor of tffjjee, • .tt
where the property is located during the twelve(12)months before March 37 of each year the deductl&/" .!gntC
to ch • - • • • • a '
See reverse side for additional instructions and qualifications.
Applicant(owner cr contract buyer-see restrictions on reverse side)
Mark A. Fehrenbacher ,
Taxing District Key number/legal description Record number Page number
Ft. Branch 26-19-18-304-000.306-026 all l h-,�1
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?
$85,000.00 p Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other than spouse,indicate with whom
I
If name on record is different than that of ape/rant,indicate below: Is the property in question:Annually Assessed
I7) Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
American Mortgage Service Company
Address of mortgagee or contract seller(number and street,city,sate,and ZIP code)
4707 Theatre Dr. Evansville, IN 47715
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city.sate,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 on property for
in Indiana? ❑Yes io current year? ❑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. I
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor County I 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 I contract buyer of the aforementioned property on date application is filed.
Signature(gwnees full n e Date(month,day,year)
hARA 4 ) ; 12/30/2015
Full resident address of applicant(number and street,city,state,and ZIP code)
801 E. Locust Ft. Branch, IN 47648
Person authorized by duty 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,sate,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.