Mortgage_Ashby �q STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS I County I Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
-` State Prescribed 43709 par/10.15)
a, + Prescribed by Department of Local Government Finance
INSTRUCTIONS:
To be filed in person or by mail. F rt�{ieQ,}+p}�
Filing Dates: 1)Real Property:Must be completed and dated in the calendar year for which the deduction is sought. JUN 3 C U I b
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is County Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ Co rder
2)Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county�////����j�,,�
where the property is located during the twelve(12)months before March 31 of each year the deduction is sougt& �f5
See reverse side for additional instructions and qualifications. G I BSO N COUNTY AUDITOR
Applicant(owner or contract buyer-see restrictions on reverse side)
Garrett R. Ashby,
Taxing District Key number/legal description R umbe P e number
Co I k rr b rA 26-14-19-104-000.960-006 01 — "a3 S1
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 or ffuitable gaTer?
is St , /00. 00 104,080.00 LJ 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
p Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
German American Bancorp
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
711 Main Street, PO Box 360, Jasper, IN 47546
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 any 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?
I ❑
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 recorders office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount cif:
20 20 _ 20 20 20 20 20
Signature of County Auditor County 1 Date(month,day,year)
I 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.
Sign u (o as me Date(monM,day,yea
not � /1 if
Pull resident address of applicant( ben and street.city,state,and ZIP code)
1857 S 1190 E;Oakland City, IN, 47660
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 line not to exceed$10,000.