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"F-,4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
of FOR DEDUCTION FROM ASSESSED VALUATION Gibson 0 ZS— 2020
State Form 43709(R14/1-20)
a _ Y, RECEIVED
+egg Prescribed by Department of Local Government Finance
DEC 3 A File Mark
INSTRUCTIONS: To be filed in person or by mail. C C G I 0 202U Form�r filed with:
l�J
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. 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)
Andrew Benjamin Burkett
Taxing District Key number/legal description Record number Pageeagmber
F anch Z�0 26-18-27-300-000.606-025/PT W SW 27-3-11 5.39 AC D-2 ?-,O "`"`'{{{�9
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 $70,000.00 WYes El 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 0 Annually Assessed
_ Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller Fi 4
Evansville Teachers Federal Credit Union - ",
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
4401 Theater Drive, Evansville, IN 47715 DEC 312020
Name of assignee or other owner or holder of mortgage
n �
Address of assignee(number and street,city,state,and ZIP code) 4�/
GIBSON COUNTY AUDITOR
Does applicant own property in any If yes,what county? What Taxing District? Has this deducti n een requested If yes,state amount of deduction
other county on property for j Yes ❑ No
in Indiana? ❑ Yes llo current year? 'p�`
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
Signature of County Auditor County Dal! th,da , i_ear)^
1V1\ 1 Gibson I [� 3` ']vr'} 1/V
I/We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resid t of ndiana and
ow er/contract buyer of the aforementioned property on date application is filed.
Si ure(ow r's ful name) Date(month,day,year)
11/23/2020
Full resident address of applicant(nu ber an street,city,state,and ZIP code)
3490 W. 950 S., Fort Branch, IN 47648
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 LID to two and a half years and a fine not to exceed S10.000.