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<Am?, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township I Year
3° FOR DEDUCTION FROM ASSESSED VALUATION — /// 7n �I
j' State Form 43709(R13/10-15) /? r' / $ONI GAIL,� /- ro/�+
' Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail f •
Filing Dates: 1)Real Property:Must be completed and dated in the calendar year for which the deduction is sought. y.- ;le'
Must be filed or postmarked with the County Auditor or County Recorder of the county where the prope I nrrrr' Auditor
located on or before January 5 of the immediately succeeding calendar year. ounty Recorder
2)Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the c 3112
where the property is located during the twelve(12)months before March 31 of each year the deduction is s ht.
See reverse side for additional instructions and qualifications.
A .I__•i poIITT
Applicant(owner or contract buyer-see restrictions on reverse side) G®$eprCo9 ' . OR•Nancy C. Dike , R
Taxing D' trict Key number/legal description Rrenb Pa u
7.(A/ 'o f 26-18-24-202-000.016-026 a l
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 orrepuitable gwpeR
40,300.00 56,000.00 LI Yes LJ 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
United Fidelity Bank, FSB
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
18 NW Fourth St., 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 perry in any If yes,what county? What Ta n District? Has this deduction been request If yes,state amount of deduction
other county � on property for
in Indiana? Yes ❑No ( T j`j C O i y$; currnt ear? ❑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)
/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)
ter, e., .1i 105/30/18
Fun resident add(%s of applicant(number and street,city,state,and ZIP code)
306 S Cumberland Street, Fort Branch, IN, 47648
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.