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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
fState Form 43709(R14/1-20) Gibson � y 2021
Prescribed by Department of Local Government FinanceJ , .-- �`lC"
INSTRUCTIONS:To be filed in person or by mail. r�� 1 StYVs , W ;21 File Mark
Form f ed with:
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)
MADELINE G.ATKINS
Taxing District Key number/legal description Reco_rd number a e n 1 P cc
CcI�kr wTu„,? 26-13-32-300-000.982-004
k.
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 stable owner?
96,566.00 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: FILED I t Real propertyProperty in question:AnnuallyAnnuallyAssessed Assessed
❑
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
ACCEPTANCE HOME MORTGAGE,LLC JAN 0 5 2022
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
1221 N.Royal Ave.,Evansville,IN 47715 � �/Ydz ..�
Name of assignee or other owner or holder of mortgage GIBBON COUNTY AUDITOR
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in a If yes,what county? What Taxing District? Has this deductio' .-en requested If yes,state amount of deduction
other county on property for i
in Indiana? ❑Yes No current year? �i Yes ❑No
A person is not entitled to this 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 Audit r 0 County \,.—O Date( on cry,year)
I/We certify under the penalty of perjury that the abo nd foregoing information is tit a and correct and that the applica t is resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signature(owner's full name) Date(month,day,year)
ul
l-1pn,� , ^)(j/ W
of1 V'"-� October 27,2021
Full resident address of applicant(number and street,city,state.and ZIP code)
4091 S 675 E,Francisco,IN 47649-9167
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month.day,year)
October 27,2021
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 MORTGAGEF� OR CONTRACT INDEBTEDNESS
Name of applicant F T T r/ m rtgag (contract seller r
MADELINE G.ATKINS ��,(�
Date filed(month,day,-year) Amount of indebtedness Taxing District ^ k.i r
Key number/legal description Z\—
26-13-32-300-000.982-004 r
Signature of County Auditor/County Reco jar ../ . ,2e&ffity Date(mon h,day,,wear)
n/���` �"� v-VS BSON COUNTY ,Ac..+ O� Z/L