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4 4, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES unty Township Year
4 c.�--FOR DEDUCTION FROM ASSESSED VALUATION Gibson 02� 2021
a ,
, State Form 43709(R14/1-20) ,
' Prescribed by Department of Local Government Finance Fur o a i�
.ern
FEB 18 2021 File Mark
INSTRUCTIONS: �� Form filed with:
To be filed in person or by maiL
Filing Dates:1)Real Property:Must be completed and dated in the calendar year for which the deduction is sought. /11(County Auditor
• Must be filed or postmarked with the County Auditor or County Recorder of the county where the I ElCounty Recorder
property is located on or before January 5 of the immediately succeeding calendar year.
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)
Carrie Coomer Clem ,
Taxing District Key number/legal description Remu,mper Page r
-Union-- 0� 26-19-18-304-000.430-026 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 le r equitable owner?
$79,400.00 88,350.00 0 No
If no,what is his/her exact share of interest? I If owned with someone other than spouse,indicate with whom -
I
If name on record is different than that of applicant,indicate below: Is the.roperty in question:Annually Assessed
"al Property 0 Annually Assessed
+ Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Old National Bank F/LE
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) ,
PO Box 918, Evansville, IN 47706
FEB IS 2021
.
Name of assignee or other owner or holder of mortgage ,,dd
Address of assignee(number and street,city,state,and ZIP code) /�� C./n�✓. wGkvridl
GIBSON COUNTY AUDITOR
Does applicant own prope in any If yes,what county? What Taxing District? Has this deduct' een requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes o current year? Yes ❑No
A person is not entitled to s deduction unless the person has a balance on the person's mortgage or n ct 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 Auditor���, Q
s\ County l�j Date(month,; yeg21 2. !
-1/We certify under the penalty of perjury tha ove-and-foregoing-information-is -and correct and-that the applicant is_a resident of Indiana and- -
o ner 1 contract buye of the aforementioned property on date application is filed.
ign kaddressofacantnurnberafld
,day,year)stye i ,state,and ZIP code)
802 E Walnut St, Fort Branch, IN, 47648-1240
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 perjury can include imprisonment up to two and a half years and a fine not to exceed$10.000. 47333