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/ •�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
N__ ' FOR DEDUCTION FROM ASSESSED VALUATION
L State Form 43709(R13/10-15) y� ccTT;;'''bs Patoka 2018
�,m„ + Prescribed by Department of Local Government Finance l�
INSTRUCTIONS: iSf e Mark
To be filed in person or by mail. Form led with:
Filing Dates: 1) Real Properly:Must be completed and dated in the calendar year for which the deduction i0�,,¢¢0g ll�1� 8p.� 77
Must be filed or postmarked with the County Auditor or County Recorder of the county whete'the plop rty as County 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 Auer of.the u
where the property is located during the twelve(12)months before March 31 of each year th ht.
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR
Applicant(owner or contract buyer-see restrictions on reverse side)
Darlene S. Kay
Taxing District Key number I legal description Reco number � Pa umbe
Patoka 26-04-24-300-000.199-020 .io r ( 1 t'
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I 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?
57,900.00 21,850.00 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 ACVssed
GI Real Property ❑ Annually 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 ny 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 perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
Signature(owner's full name Date(month,day ear)
SlZal(I
Full r !dent address of applicant(number and street,city,state,and ZIP code)
208 NE Mill Street, Patoka, IN 47666
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.