Homestead_Kingsbury STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS CountyTownshipYear
FOR DEDUCTION FROM ASSESSED VALUATION
llept
b State Form 43709(R13/10-15) ib n ka
' Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail. �f G 2 4 ZOZO Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is soug
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is ❑✓1 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 f
where the property is located during the twelve(12)months before March 31 of each yearllt�r�e tir�n gt1t.A R
See reverse side for additional instructions and qualifications. CC��1
Applicant(owner or contract buyer-see restrictions on reverse side)
Chad A Kingsbury
Taxing District Key number/legal description Record number Page number
Patoka 26-12-09-103-004.590-027 , t) ?Li(e Z
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?
$228,000 p 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
LNB Community Bank
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
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
in Indiana? Yes No current year? ✓❑CI Yes ❑No $3,000
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
Signaturnty Auditor County Date(month,day,year)i�
I/We certify under the penalty of perjury tha the ove and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract-buyer-of the aforementioned pro erty on date application is filed.
Si�gnat wners"full name) Date month;:day,year)
/l j7 z4)
u resident address of applican (numb e city,state,and ZIP code)
1460 E Indian Creek at rin`deton IN 47670
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 penury can include imprisonment Up to two and a half years and a fine not to exceed$10,000.