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•72v STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County I Township I Year
FOR DEDUCTION FROM ASSESSED VALUATION t � y]
5'� State Form 43709(R13/10-15) /„)a5d)� WaA & 2011
Prescribed by Deparent of Local Government Finance I
INSTRUCTIONS: File Mark
To be filed in person or by mail. Form filed with:
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 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 tile 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.
Applicant(owner or contract buyer-see restrictions on reverse side) //
Michael T. Collins , qt-03J9- /0 5f- 6163. 896 -a/7
Taxing District Key number/legal description RecZu Pa umber.
Washington 26055710a0004600,o ' tt3
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the ape'. the sole
assessment date,current year assessment date,current year date of application legal o stable inner?
43,320.00 135,500.00 Yes inner?
No
It no,what is his/her exact share of interest? If owned with someone other than spouse,ind' te with whom
If name on record is different than that of applicant,indicate below: Is property in question:Annually Assessed
Real
M it iC 6-1.1-7)
Name of mortgagee or contract seller ,
Fifth Third Mortgage Company
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) JUL 0 6 2018
3251 N Green River Rd MD k48021, Evansville, IN 47715
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code) GIBSON COUNTY AUDITOR
• 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 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 contr.N buyer if the affoo lementioned property on date application is filed.
Signature • J s(tilt,•- ,41 /' Date(month,day,year)07/02/18
Full resident,ddress of applicant(number and street,city.state,and ZIP code)
4651 N SR 65, 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.