HomeMy WebLinkAboutMortgage_Goldbach _.•01P-.77 , STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
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4%131 FOR DEDUCTION FROM ASSESSED VALUATION
• ,',... Gibson 0-74:-) 2021
.,..... -- State Form 43709(R14/1-20)
16.5 Prescribed by Department of Local Government Finance ,. . ..—._.._.
( ....
-. , File Mark
INSTRUCTIONS: To be filed in person or by mail. Q.... C..- I Nov - , 1 Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. IRI 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. 0 County Recorder
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Kenneth C.Goldbach and Robin A. Goldbach
Taxing Distr)wi---... Key number/legal description Record number F;age nipayer
Patoka 10\._>- If\ . 26-04-25-300-000.653-020/Hudson Farm West Ph 2 Lot 5 "*2,,-,0 a I
Assessed
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 $300,000.00 El Yes 0 No
If no,what is his/her exact share of interest? ir I 1 .jfeied with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: I . 111-"I Is the property in question:Annually Assessed
El Real Property 0 Annually Assessed
DEC 0 1. 2021 Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
The First National Bank of Carmi
Address of mortgagee or contract seller(number and street,city,statAlottailtehic4 . ik464.4141)
201 E. Main Street, Carmi, IL 62821 GIBSON COUNTY AUDITOR
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code) (111
Does applicant own property in any If yes,what county? What Taxing District? 1 Has this ded bony- equ s d If yes,state amount of deduction
other county ,-, on property f.r ....„
in Indiana? I—IYes 0 No current year Mr Z.• No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage . c.nt tin eb dness 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) at is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20
1 20 20 20
Signature of Couly,estAuccALizlet '''----"i County Da\e 0 a yr)2/‘
Gibson
I/We certify under penalty of perjury that4.5 ove and foregoing information is true and correct and that the applicant is a resid nt of ndiana and
owner/contract buyer of the aforementioned property on date applicatio 's filed.
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Xture
ull r sident address of applicant(number and street,city,state,and ZIP code)
601 Cardinal Dr., Patoka, IN 47666
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.