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^; v STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
° FOR DEDUCTION FROM ASSESSED VALUATION y
clot State Form 43709(R12/6-14)
->' Prescribed by Department of Local Government Finance
INSTRUCTIONS: ,iLj JFlle Mark
To be filed in person or by mail. ! 9L'J. eA/d Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the dAVucti n is sought.
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. I I I hI 6 2016 ID County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the Countj? othtor of the county
where the property is located during the Twelve(12)months before March 31 of each year the deduction is sought.
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Reinbrecht, Jacob GIBSON COUNTY AUDITOR
Taxing District Key number/legal description Record number Page number
Johnson 26-19-34-400-000-412.024/Pt SE 34-3-10 1.19A - ;a a.1
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appl t the sole
March 1,cement year March 1,current year date of application legal or eq ble owner?
162,600 96,000 148,000 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,r6Oerry in question:Annually Assessed
eat Property ❑ Annually Accessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Legence Bank
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
P.O. Box 596, Eldorado, IL 62930
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street.city,state.and ZIP code)
Does appkant own property in 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? ❑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 a-edit 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)
11 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 ropery on date application is filed.
Signal owner's II name t- Date(month,day,year)
1t�I I�5414014- T /l.//
-c./2 7//
HI resident a101oapplica and street,city,4te,antl- code) 1IG uto 1" ' c/2
1 19 7 3 -90 �G^ s /}
Person authorized by duly executed Power of Attomey 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 S10,000.