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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS C. ,:.: .0,, Township Year
a�•' 4 FOR DEDUCTION FROM ASSESSED VALUATION 1
Sate Form 43709(R13/10-15) 'b y.n I,' ontgomery 2018
• p Prescribed by Department of Local Government Finance
INSTRUCTIONS: 4 JUN 05 2017 File Mark
To be filed in person or by mail. Form filed with:
Filing Oates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought.
Must be filed or postmarked with the County Auditor or County Recorder of the county wh= - the.p •fete..; ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. 4. -4-1011110
-,-,-,RO County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the Coun •+4 r•Fp r
f� •- esppit)DI
where the property is located during the twewe(12)months before March 31 of eaOA f-- •-UbChon is sought.
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Shannon L. Holmes
Taxing District Key number/legal description Record number Page number
Montgomery 26-17-29-100-004.312-021 9017 .2338
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?
78,452.00 0 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 ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Fifth Third Mortgage Co.
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
12626 US 41 N, K63581, Evansville, IN 47725
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 0 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 aniount 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
owner/contract buyer of the aforementioned property on date application is filed.
Sig Lure(owner's full name" Date(month,day,year)
• IA OJ-w,-w. d f.ntiJ 5/� r� 1
Ful resident address of appgdant(number and sheet,city,state,and ZIP code)
8972 S. 1125 W., Owensville, IN 47665
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 sheet,city,sate,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 810,000.