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Mortgage_Bird ^•�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year a.._,, FOR DEDUCTION FROM ASSESSED VALUATION �f1 s ! State Form 43709(R13/10-15) Gibsa�—� ILE 2018 Prescribed by Department of Local Government Finance • g File Mark INSTRUCTIONS: �1 q To be filed in person or by mail. APR 1'Or1©l&ith: 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 IA County Auditor located on or before January 5 of the immediately succeeding calendar year iy Recorder 2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the co where the property is located during the twelve(12)months before March 31 of each year the dedtf$yg$sr U N7y AUDITOR See reverse side for additional instructions and qualifications. Applicant(owner or contact buyer-see restrictions on reverse side) Susan R Bird Taring District Key number/legal description Record number Page number Johnson 26-23-16-200-002.486-024 all Y tSSO 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 agw«ment date,current year date of application legal or equitable owner? 262700.00 249600.00 it Yes ❑ No It 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 Assessed Old National Bank 01 Real Property ❑ Mobie H 6-1.1-7) Name of mortgagee or contract seller 3535 N Green River Rd, Evansville, IN 47715 Address of mortgagee or contract seller(number and street dry,state,and ZIP code) 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 , property for in Indiana? Yes No anent 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/con cr buyer of the aforementioned property on date application is filed. Signature(o s full name) 1 �. r) . 1 Date(month,da year) Vw� /hJ L► I (I) t g Full resident address of applicant(number and street,city,state,and ZIP code) 1691 E Autumn Ridge, 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 two and a half years and a fine not to exceed 310,000.