HomeMy WebLinkAboutMortgage_Selby aF�vnc STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
:-._ ' FOR DEDUCTION FROM ASSESSED VALUATION
Sj State Form 43709(R12/6.14)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mait rm filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction u tT. �
Must be filed or postmarked with the County Auditor or County Recorder of the county wh th r I County 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 tile with the County Auditor of the ooJjjnb�''„11
where the properly is located during the twelve(12)months before March 31 of each year the deMi onOtoakt6
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Thomas D Selby and Caryn M Selby ,u -
Taxing District Key number/legal description GIBSON COUNLYieltrarrTOR Pale n tuber
Union 26-19-18-101-001.165-026 35
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness u paid as of Is the.applicant the sole
March 1,current year March 1,current year date of application legal or equitable owner?
266,211.00 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
e2 Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
First Security Bank Inc.
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
300 Frederica St. PO Box 788 Owensboro, IN 42301
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 on property for
in Indiana? Yes ❑
No current year?
Ill Yes S 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.
!nature(owner's lull o Date(month,day,year)
$/yea` s/.� /
Full resident a dress of applicant(number.nd street.city,state.and ZIP code) /
807 Creek Drive, Fort 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,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.