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e STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
ie_ _,I : FOR DEDUCTION FROM ASSESSED VALUATION g Form• Presribea by0Deparmento 8 l ft�
� � Prescribed by Department of Local Government Finance
INSTRUCTIONS:
To be filed in person or by mail. All q ,. Fwn red with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. !i CU
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.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the.'� _inning/
R. Recorder
where the property is located during the twelve(12)months before March 31 of each year the dentition Ilc}.J.. grtmr.,
See reverse side for additional instructions and qualifications. GIBSON C•UNTY AUDITOR
Applicant(ownecor contract buyer-see restrictions on reverse side)
DunnjRoy D.
Taxing District Key number/legal description Record number Page number
Princeton 26-11-13-204-002.607-028/Mckaw Sum 100/101 Pt 0o t1— 3
Assessed value of real properly as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitab4 ner?
68,500 95,805 89,900 es ❑ 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 erty in question:Annually Assessed
eal Property ❑ Annually Assessed
Mobile Home(1C 6-1.1-7)
Name of mortgagee or contract seller
Ruoff Mortgage Company, Inc.
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
1110 East Dupont Rd., Ft. Wayne, IN 46825
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 a 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 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 perju that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract b he aforem lone roperty on date application is filed.
Sgx\gature(comer na Date(month,d yea
/ Z_,
Fall esident add s of appli tnumbe rid street,city,state,and ZIP code)
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.