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4 Q STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
Prescribed Form 43709(R12 Department b. Presrfibed by Department of Local Government Finance ,JeNTi�./ •
INSTRUCTIONS: - - l e Mlart - -
To be filed in person or by malt Z"8'faec�wm.
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. FEB CD U C U I O
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. C gi2Efiorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the coun
where the property is located during the twelve(12)months before March 31 of each year the deduction is SO U NTY�AU DITOR
See reverse side for additional instructions and qualifications. ((ii CCJ
Applicant(owner or contract buyer-see restrictions on reverse side)
STEPHANIE M. BENGERT
Taxing District Key number I legal descdptio22,� Record number Page number
OWENSVILLE 26-17-01-404-01104-022 � (� - 56S,
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,ardent year March 1,current year date of application legal or equitable owner?
$127,652.00 p Yes ❑ No
If no,what is his/her exact share of interest? It owned with someone other than spouse,indicate with whom •
If name on record is deferent than that of applicant,indicate below: Is the property in question:Annually Assessed
IN Real Property ❑ Annually Accessed
Motile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
CALIBER HOME LOANS, INC.
Address of mortgagee or contract seller(number and street.city,state,and ZIP code)
3701 REGENT BLVD., SUITE 180. IRVING, TEXAS 75063
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? Wnat 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 ❑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. -.
Signature( ne/s to name) Date(month.day,year)
� �i �jj
01/ /5 /2016
Full reside address of applicant(number an t.city,state,and ZIP code)
204 N. 3RD STREET, 0 NSVILLE, INDIANA 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.