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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
4 FOR DEDUCTION FROM ASSESSED VALUATION
State 43709(R12 1 6-14) Gibson Johnson
� �` Prescribed Form by Department of Local Government Finance �'�1
To INSTRUCTIONS:fin person �I of
To be filed in person or by mail. Fo ea i
Filing Dates: 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 where the property is ❑ County n Auditor
located on or before January 5 of the immediately succeeding calendar year. JAN 2$ eta Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
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. of scr
Applicant(owner or contract buyer-see restrictions on reverse side)
Matthew E. Schmitt and Jill Ann Schmitt GIBSON COUNTY AUDITOR
Taxing District Key number/legal description Record number Page number
Johnson 26-23-18-100-000.265-024 a01%_ 33a-
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,anent year March 1,current year date of application legal or equitable owner?
172800.00 p 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
0 Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Fifth Third Mortgage Company
Address of mortgagee or contract seller(number end street city,state.and ZIP code)
5001 Kingsley Dr., Cincinnati, OH 45227
Name of assignee or other owner or holder of mortgage
Address of assignee(number end street,city,state,and ZIP code)
Does applicant own property in any If yes 11r/county? What Taxing District? Has this deduction been requ ed If yes,state amount of deduction
in Indiana? f R on property
yearn
finer county Yes 0 N / Q 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 fine 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 owner's full name) Date(month,day,year)
ull silent address of applicant(number and street,city,slate.and ZIP code) t /, y/;,
12472 S 40 W, Haubstadt, In 47639
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 Iwo and a hall years and a fine not to exceed 510,000.