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fi t�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
i- > FOR DEDUCTION FROM ASSESSED VALUATION
Ni ,. "'= Gibson Johnson 2020
`ti ..i State Form 43709(R14/1-20)
ieig_ Prescribed by Department of Local Government Finance • - RECEIVED •
r File Mark
INSTRUCTIONS: To be filed in person or by mail. (10y-C. ) J U L 2 2 2019 Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. u County Auditor
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 calendar year in which the property taxes are first due and payable. ❑ County Recorder.
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side) •
Forest Tanner Kolley
Taxing District Key number/legal description Record number Page number
Johnson 26-18-36-300-002.776-024/Hunters Crossing 2 Lot 208 1 3 El-
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?
$0.00 $238,950.00 ID 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
❑x Real Property 0 Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller Fifth Third Bank, National Association FILE ilk
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
5001 Kingsley Drive; MD:1 MOBA8, Cincinnati,OH 45227 JUL 31 2020
Name of assignee or other owner or holder of mortgage �6 }
Address of assignee(number and street,city,state,and ZIP code) `0(12 u��}��
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 deduction
other county on property for ❑Yes ❑ NO
in Indiana? ❑Yes El NO current year?
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 Ai j 20 20 20 20 20
Signature of County Auditor ,,1 County Date(month,day,year)
t� �JN' G Gibson -7 •21. 2 Zo
I 1 We certify under penalty of perjury that the above oregoing 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.
Signature(owner's full name) ,.ba (month,day,year)
7- q 7fao
Full resident address of applicant(number and stt,city,state,and ZIP code)
1301 W CHUKAR HOLLOW RD HAUBSTADT IN 47639
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)
The penalties for oeriury can include imprisonment up to two and a half years and a fine not to exceed$10,000.