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n,44 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
. FOR DEDUCTION FROM ASSESSED VALUATIONREcov �. yState Form 43709(R14/1-20) Gibson ,, 9-0 21�° Prescribed by Department of Local Government Finance nil
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MAR 01 0 1 File Mark
INSTRUCTIONS: To be filed in person or by mail. Syv. \3 \
\ Form filed with:
Filing Date: Form must be completed and dated in the calends year for wh h the de con is sought. IZI County Auditor
Must be filed or postmarked with the County Auditor or County ecorder 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. 0 County Recorder
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Anissa L. Maikranz TEL-812-459-1305
Taxing District Key number!legal description Record number Page number
Haubstadt 26-19-31-400-000.715-009 100/1 . lGS G.
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?
$92,000.00 ( 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
Feal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller I
German American Bank
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) MAR 0 3 2021
711 Main St., Jasper, IN 47546
Name of assignee or other owner or holder of mortgage
fit/ a. . ,.
Address of assignee(number and street,city,state,and ZIP code) GIBBON COUNTY AUDITOR
Does applicant own property in any if yes,what county? What Taxing District? Has this deduction bee . equested If yes,state amount of deduction
other coun
in Indiana? ❑Yes VI No currrentt year?r es 0 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 Auditor� ( County Date month,day,year)ea
W� \� �Sov� 3- 2- W2,
I/We certify under the penalty of perjury that the above and foregoing information is ti4 and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signat_ (owner's full name) l �- v`-`/ Date(month,day,year)
C t 02/23/2021
Full resident address of applicant(number and street,city,state,and ZI ode)
202 S Fifth Ave., 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)
The penalties for perjury can include imprisonment upto two and a half years and a fine not to exceed S10,000.
RECEIPT FOR FILING STATEMENT OF MOR GE OR CONTRACT INDEBTEDNESS
Na a of applicant Na e rt gee o?+: . -; er
91ui4j 7# ,
!�!SSA iY)4-I K ,, r c �! 1�
Date filed(month,day,yea Amount of indebtedness I ng District
��
3 2:n.02\ $92,000.14AR 0 3 2O q Haubstadt
Key number/legal description 2021
26-19-31-400-000.715-009 2•02\ - [O SI
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Signature of County Auditor/Coun '- .der l Rf 4r,, Date(month,day,year)
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COUN IY AUDITOR .3.2 `'°2