Mortgage_Moody 1eR,� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESSCountyTownship
�/,�r�� Year
�-fit FOR DEDUCTION FROM ASSESSED VALUATION
'�` a''= ( ) Gibson Johnson 2020
State Form 43709 R14/1-20
.. ,•,i"" Prescribed by Department of Local Government Finance
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File Mark
INSTRUCTIONS: To be filed in person or by mail.
Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. Z 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
- Record number Page number
Johnson 26-22-14-300-001.609-024 2I7l-/5416
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?
$ $155,000 lYes ❑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 n—y
Fifth Third Bank - F-1--71 � iii
Address of mortgagee or contract seller(number and st) ) ! i•—
Drawer NO
Ul \d
Name of assignee or other owner or holder of mortgage S E P 14 ZU ZU
Address of assignee(number and street,city,state,and Card NO. S�
Does applicant wn property in any If y ,what county? What Taxing District? Has this deduction been WilMtkiliN @ c ) aTeYan f, ption
other county IJ�O o proprty fo
in Indiana? Yes ❑No 4ndeb(A/ currenntyeear?r ❑Yes ,No
A person is not entitled to this deduction unless th erson 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
Signat of unty Auditor . County Date(month,day,year)
1 , S(Y1-- 9 -/'f-2o2.0
I/ e certify under the p of perjury that the a ve and foregoing information is true and correct and that the applicant is a resident of Indiana and
er/contract buyer of the aforementioned property on date application is filed.
Signature(owner's full name) 1 Date(month,day,year)
I1 l� 7, ,,A��e� �' -2� 9/14/2020
Full residents-address of?applicant(number and str t,city,state,and ZIP code) ��
12887 S. Sunset Drive, Haubsta t, 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)
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