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.0'--' STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County ..Township Year
e FOR DEDUCTION FROM ASSESSED VALUATION
¢"; Gibson OQC+ 2021
~:4g , State Form 43709(R14/1-20) F
\% `? Prescribed by Department of Local Government Finance Y J- �VED •
File Mark
INSTRUCTIONS: To be filed in person or by mail. (3.0S_S-L 1 MAR 0 2 2021 r
FormFo filed with:
RI 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)
Jason A. Miller and Sara M. Miller ,
Taxing District Key number/legal description Record number Pa nu ber
Haubstadt 26-18-36-404-000.237-009/PT SE 36-3-11 .53 AC .7.-.1z. 21 l • 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?
$0.00 $175,250.00 Q Yes 0 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
Property Annually Assessed
fJ111 3,a1 ❑Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Evansville Teachers Federal Credit Union MAR 0 3 2021
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
4401 Theater Drive, Evansville, IN 47715 Name of assignee or other owner or holder of mortgage i,2,,‘Ald a. v t
GIBSON COUNTY AUDITOR
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 deducti been requested 'If yes,state amount of deduction
other county El on property for
in Indiana? RI No � current year? Yes Q No
A person is not entitled to this deduction unless the person has a balance on the persons mortgage o con act 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 amft of:
20 20 20 20 20 20 20
Signature of County Auditor County Date(month,day,year)
M100c41; Gibson 3.2• 'l2-1
II We certify under penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Si to wner's f me) Was Date(month,day,year)
(�G . �1 ---� 01/15/2021
Full resident address of applicant(number and street,city,state,and ZIP code) �
405 W. Elm St., Haubstadt, 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)