Mortgage_Bailley STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
9 4 FOR DEDUCTION FROM ASSESSED VALUATION
si. State Form 43709(R13/10-15) ?pica 2018
\, ate Prescribed byDepartment of Local Government Finance
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F balk
INSTRUCTIONS:
To be filed in person or by mail. Form rued with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is soqg0.r 1 q 2018
Must be filed or postmarked with the County Auditor or County Recorder of the county where th prop ❑ 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 the county
where the property is located dining the twelve(12)months before March 31 of each year the d IYA �nr) � _
See reverse side for additional instructions and qualifications. ,.:,_f.. r .�tnrTr�D
CICC_': ___... . . . ..
Applicant(owner or contract buyer-see restrictions on reverse side)
Larry W. Bailey .
Taxing District Key number/legal description Req^numbly Page number
26-12-19-400-001.133-027 0(�-� L O q qaD
Assessed valued real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
4600.00 45000.00 46000.00 p Yes 0 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
0 Real Property 0 Mobile 11ssed
-jomee(ICC 6-1.1-7)
Name of mortgagee or contract seller
First National Bank of Carmi
Address of mortgage or contract seller(number and street,city,state,and ZIP code)
209 E. Main Street, Carmi, IL 62821
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 0 No
in Indiana? ❑Yes 0No current year? ❑yes
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 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 contract buyer of the aforementioned property on date application is filed.
&Snatur (owners full name) Date(month,day,year)
Full rest address bf applicant(number ago( trees,city,state,and ZIP code)
21727 5 , SPe PThocc_ loA.) _1-A) 44 '76PD
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,cay 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.