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E "n. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
„e-_,_ `s FOR DEDUCTION FROM ASSESSED VALUATION
Sate Form 43709(R13/10.15) , /. •
2018
�• , Prescribed by Department of Local Government Finance .
INSTRUCTIONS: File - ,1111
To be filed in person or by mail. APR 1 o faed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. ,
l 2
Must be filed or postmarked with the County Auditor or County Recorder of the county where the prope`• is `ounty 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 file with the County AudrtitieSt 4%fi rignic
where the property is xated during the twelve(12)months before March 31 of each year the deductso sera
See reverse side for additional instructions and qualifications. Ty
Lipp-
Applicant Applicant(owner or
Obert
Taxing District Key number/legal description Re rd nu ber Page number
Fort Branch 26-19-19-204-001.321-026Ol \S \�
Assessed value of real property 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 equitable owner?
125,700.00 156,750.00 El 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
TA Real Property ❑ Annualy Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Old National Bank
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
One Main Street, Evansville, IN 47708
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 y If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other 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 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
y P y Pefl ry 9 9 PP
owner/co act buyer oft aforementioned property on date application is filed.
' re(a e ts nam Z:1264_1‘-- Date(moor,ly, ar) ^
Full resident address of applicant(number and street,dry,state,and ZIP code)
420 E. 795 S., 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 sweet,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.