HomeMy WebLinkAboutMortgage_Shainrs
nnvg. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION 2019"•� tt< State Form 43709(R13/10-15)
'o3'=/ Prescribed by Department of Local Government Finance File Mark
HIM
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 0
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)
Kimberly Elizabeth Shain
Taxing District Key number/legal description 26-18-13-403-000.324-026/ Record number Page number
Ica-cab c�
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 equitable owner?
$150,100.00 ❑Yes ❑ 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 wally Assessed
❑ pe ally Assessed
ile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Republic Bank&Trust Company 4 41Q19
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) MN
601 W Market St, Louisville, KY 40202
Name of assignee or other owner or holder of mortgage • , OR
T' 11N1V A
Address of assignee(number and street,city state,and ZIP code) G1gS°
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 0 No current year 0 Yes 0 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
Sig lure of County Auditor County Date(month,rdaay,year)
• `� r S-aH -L R
I/We certify under pena ty o perjury t t above and foregoing is true and correct and that the applicant is a resident of Indiana and
owner/ ntract buyer of the aforemention d property o date application is filed.
Signs wne full me) ( � � Date(moetay,year)
• os i9
Full resident address pplicant(num r and street,city, te,and ZIP code)
203 S West St., Fort Branch, IN 47648
Person authorized by duty executed Power of Attomey 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 S 10,000.