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.o•r`i.o STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
it FOR DEDUCTION FROM ASSESSED VALUATION -
State Form 43709(R13/10-15) u`S%911 'c rite ' 2019
'e ? Prescribed by Department of Local Government Finance File Mark
4P
INSTRUCTIONS:
To be filled inProperty:person or mail. Fym fled with:
Dates:
Filing Dates: 1)Real P 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)
Scott L.Mason and Jacklyn S. Mason
Taxing D1s Key number/legal description 26-19-19-204-001.329-026/ Record number Page nu be
z0t• 211
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 applcation Q legal or equitable owner?
$208,000.00 2_0 000— ❑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 question: Annually Assessed
❑ Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller FILED
Heritage Federal Credit Union
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
5388 Old State Highway 66, Newburgh, IN 47629 JUN 0 4 2019
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 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 ❑ 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 1 f 20 20 20 20 20
Signature u.tor mirk Count c.c W Date(mo . , ,ye r) ,
I/We certify under penalty of perjury that the abov d fa going information is true and correct and that the a plhtis a resident of Indiana and
owner/contract buyer of the aforementioned propn date application is filed.
(Stur owner's full name Date(month,day,year)
utl re en adressof ap Scant(number and street, i ate,andLIP code)
423 E 795 S, Fort Branch, IN 47648
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,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.