HomeMy WebLinkAboutMortgage_Keeker STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R14/1-20) Gibson 0 0 4 zeo 24
Prescribed by Department of Local Government Finapce
--,_,_,..m......I LILL. 0 7 7021 File Mark
INSTRUCTIONS: To be filed in person or by mail. IFIV4Itiki Ii r 1 e t(3,3 CA. Form filed with:
Filing Date: Form must be completed and dated in the cal year for with the deduction is sought. 0 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)
Samantha Keeker
Taxing District Key number/legal description Record number Pa4erscr
Center 26-13-30-100-000.512-004 1'20 2.\
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?
$69,000.00 ik)Yes C3 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
F ILED WI Real Property El Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
German American Bank
Address of mortgagee or contract seller(number and street,city,state,and ZIP codebEc 1 4 zozi
711 Main St., Jasper, IN 47546
Name of assignee or other owner or holder of mortgage
tAite41 .1.'
Address of assignee(number and street,city,state,and ZIP code) GIBSON GouNIN ;..0.)
Does applicant own property in any If yes,what county? What Taxing District? Has this deducti b en requested If yes,state amount of deduction
other county on property for
in Indiana? El Yes 10 No current year? Yes CD No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or nt 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
Atm,
Signature itICriunty udi - tati County
k. Dater21,mat 14
I/We certify under the penalty o .-jury that the above and foregoing information is tru a d correct and that the applicant is a resid o
nt of Indiana and
ner/contract buyer of the aforementioned property on date application is filed.
Si ,ure(owner's full name) Date(month,day,year)
., 12/09/2021
. t
Full resident address of applicant(number and street,city,state,and ZIP code)
5611 E 250 S. Francisco, IN 47649
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.
RECEIPT FOR FILING STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
Name of applicant Name of mortgagee or contract seller
Samantha Keeker German American Bank
\R
Date filed((month, Amount of indriI6sHG:ED Taxing District Center r
C
Key number/legal description c--,
26-13-30-100-000.512-004 DEC 1 laR21 7-021 - 13- g
.
Signature of County Auditor Cou t Rqcor.- Date(month,day,year)
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GIBSON COUNTY AUDITOR