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AsuN STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
5State Form 43709(R13/10-15) 2019
_ Prescribed by Department of Local Government Finance File Mark
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INSTRUCTIONS:
To be filled 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 located on or before January 5 of the immediately succeeding calendar year. County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property: Must file with the County Auditor of the ❑ County Recorder
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)
Jared Kitchene and Carol Kitchene
Taxing District Key number/legal description /6145 W Stalheim Ave. Owensville, Indiana Record number Page number
47665
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Indiana
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Indiana
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 leg equitable owner?
S719,000.00 AYes ❑ 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: property in question: Annually Assessed
Real Property ❑Annually Assessed
/ U/VVVVVV Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller FILEi,
The Federal Savings Bank 1
Address of mortgagee or contract seller(number and street,city, state,and ZIP Mae) 1 3 2019
300 N Elizabeth St, Suite 3E, Chicago, IL 60607
Name of assignee or other owner or holder of mortgage /J/b/!GAor^ `^((^��
Address of assignee(number and street,city, state,and ZIP code) GIBSON COUNTY AUDITOR
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of
other county \/! on property for deduction
in Indiana? ❑ Yes ,bli No current year? ❑ Yes ❑ No
A person is not�.--1,,,,haled to this deductir Mess the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's oft). ,�cl ding any homen •-. ty line f credit that is rde the county recorder's office)that is the basis for the deduction.
'.V CC TY AUDITOR
Deduction appro inEbb ount of, v V
20 20 20 20 20 20/ 20
Signature of County Auditor County Date(month, dar)) \C
I/We certify under penalty\a of perjury that the above and foregoing information is true and correct and that the appJlis a sident or Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
nature wner's full name) a (month,day,year)
Full resid t address of applicant(number and street,city, state,and ZIP code)
6145 W Stalheim Ave., Owensville, IN 47665
P rson au l razed by duly executed Poweuipttorney or by IC 6-1.1-12-0.7 Da e(month,day,year)
l &ce S�R0.(`. - Q C- (I- I CI
Address oo thorized 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.