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O -A,. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
° sp" FOR DEDUCTION FROM ASSESSED VALUATIO
( ) CEIJVED Gibson Montgomery 2020
�1a State Form 43709 R12/6-14
* e Prescribed by Department of Local Government Finance
INSTRUCTIONS: I _ W W 1 1,,M��� OCT 1 z(�2� File Mark
To be filed 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 property is ❑✓ 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 of the 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)
Adam Bush and Stacy Bush
Taxing District
Bush Minor Lot 3, Gibson County cx a0000 JSSL)
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current year date of application legal or equitable owner?
$218410.00 E 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
Re erty,-❑ Annually Assessed
F
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Ruoff Mortgage Company, Inc.
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) O C T 1 5 2020
1700 Magnavox Way, Suite 220, Fort Wayne, IN 46804 11.,
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code) GIBSON COUNTY AL,Di P OI-
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 L�/ on property for
❑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 20 20 20 20 20 20
Signature of County ACounty I Date(month,day,year)
Audito
*mil) So 10•`j. 2,0 20
I/We certify under the penalty of perjury that the above and foregoing information is rue and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned propert on date application is filed.
Signature(ow er's full name) Date(month,day,year)
10/2/2020
Full resident ad ress of applicant(num er and reet,city,state,and ZIP code)
4118 South 350 West, Owensville, IN 47665
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 uo to two and a half years and a fine not to exceed$10.000_