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Ra STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County I Township Year
* FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
• 1' Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS:
To be tiled 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 file 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)
SHANE NI. REMBE & HEATHER N. REMBE
Taxing District Key number/legal description 1 Recoraqumber Pace number
City of Oakland City 26-14-18-403-000.054-0071 Farmers Addition Lot 9 dC k 6 -' ;0L0
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,cement year assessment date,current year date of applii bon legal or equ' a owner?
Q 74 333. 77,777.001 es No
If no,what is his/her exact share of interest? - I 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
—N/ - Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller 9
Acceptance Capital Mortgage Corporation . �
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
101 Plaza E. Blvd. Suite 103, Evansville, IN 47715 AUG 6 2018
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street.city,state,and ZIP code) )\++r'"r-
GIBSON COUNTY AUDITOR
Does applicant own property in 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?
El ❑
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 I
Deduction approved in the amount of:
20 20 20 20 20 I 20 20
Signature of County Auditor 1 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/contract buyer of the aforementioned property on date application is filed.
Sign re(or ne?s full name) Date( d
y'\ -- --t j, h yin /
1 2018
Ful esident ss
of applicant(number an et,city,state,and ZIP code)
342 S. Jackson ST, 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)
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The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10.000.