Mortgage_Kiefer .+•^`Rat STATEMENT OF MORTGAGE OR CONTRACT I. ' :TEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATIsb. LE
/ State Form 43709(R13/10-15) Gibson Patoka 2018
�;�_• Prescribed by Department of Local Government Finance
INSTRUCTIONS: JUN 2 9 2017 File Mark
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 w - the deductio is sought
Must be filed or postmarked with the County Auditor or County Reco .:Q.f the..y...,;t - - he property is IA County Auditor
located on or before January 5 of the immediately succeeding calend. ''f' ' " U�
2) Mobile/Manufactured Homes not assessed as Real Propert}Q*.O' bents Tddr11146(p$7rO ff the county El County Recorder
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)
Ryan Kiefer
Taxing District Key number/legal description Record number Page number
Patoka 26-11-16-400-001.815-027 ao1-1 -a-1 �U
Aswssed value of real property as of Mortgage I 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?
127,200 118,750 D 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
2] Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Evansville Teachers Federal Credit Union
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
4401 Theater Dr. Evansville, IN 47715
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 an If yes,what county? VVhat Taxing District? Has this deduction been requested If yes,state amount of deduction
other county / on property for
in Indiana? ❑Yes o 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 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.
Signature(own till name) Date(month,day,year)
Full reside res applicant(number rid street,city state,and ZIP code)
1005 S 50 W, Prince on, IN 47670
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 penury can include imprisonment up to two and a half years and a fine not to exceed$10,000.