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gf�o„ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count Township Year
fret FOR DEDUCTION FROM ASSESSED VALUATION
l State Form 43709(R12/6-14) /.• 2016
Prescribed by Department of Local Government Finance
INSTRUCTIONS: File a
To be filed in person or by mail. f
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 proper 29 9AD/�., i County Auditor
located on or before January 5 of the immediately succeeding calendar year. �l -County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of unty
whem the property is located during the tweNe(12)months before March 31 of each year thededtrC
See reverse side for additional instructions and qualifications. N CAI
Applicant Ethan W Har Olbu r-see restrictions on reverse side) JNI y4
tin
Taxing District Key number/legal description Record number Page number
Ft. Branch 26-18-13-404-000.549-026 P-o 14, 71,3
Assessed value of real properly, as of Mortgage/Contact indebtedness unpaid as of Mortgage/Convect indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current year date of application legal or equitable owner?
116,600 123,500 0 Yes ❑ No
If no,what is his I 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
0 Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or corm-act seller _
First Financial Bank, N.A. \k
Address of mortgagee or contract seller(number and street,city state,and ZIP code) E-C�,..a,./.. \ I v-4 b\�e
P.O. Box 540, Terre Haute, IN 47808 W
Name of assignee or other owner or holder of mortgage 4 F\1--5\ V\v\o-mac-\tIzI\
Address of assignee(number and street,city,state,and ZIP code) qv..,' — '.0\L,'^� °-'/
Does applicant own property in a If yes,what county? What Taxing District? Has th 1�� 1 O O a.'9��—l\O r
other county on pro
in Indiana? 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 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 properly on date application is filed.
Signature(owner's lull na e c Date(mon ,day,y r)
/1 t.l 3 /) f,z Ile
Full resident address of applicant(number and street,city,state.and ZIP code)
104 E Strain St., Fort Branch, IN 47648
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.
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