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e art, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
W. S FOR DEDUCTION FROM ASSESSED VALUATION
i' State Form 43709(R11/
GIBSON JOHNSON 2016
Pres cribed by De partm ent of L ocal Government Finance File Mark
INSTRUCTIONS: �'
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for whiglt/dry d¢dyct sought.
Must be filed with the County Auditor or County Recorder of the county whb1-;khelprbpEUJIj located County Auditor
on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file wi )he County Au itor of the
county where the property is located during the twelve(12)months bolo ear the
deduction is sought. GIBSON COUNTY AUDITOR
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
SCOTT R.&DIANE M. HASENOUR
Taxing District Key number/legal description Record number Page number
JOHNSON 26-19-31-201-002.364-024 a(AL-- (IC( ` :)-■
Assessed value of real properly 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?
380,300.00 75,000.00 70,000.00 ❑ 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
❑Real Property ❑Annualy Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
FIRST NATIONAL BANK OF CARMI
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
201 MAIN STREET,CARMI, IL 62821
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 other It yes,what county? What Taxing District? Has this deduction been requested on property
county in Indiana? for current year?
❑ yes ❑ No ❑ yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20 _
Signature of County Auditor County Date(month,day,year)
II 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 tuners fue a e) Dat (month,day,year)
/D- 7-/co
Full resident address of appli t(number and street,city,sta ,and ZIP code)
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)