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*IA, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R14/1-20) �, lib 5pn }o� (ow,.I 2022
'�.'ti6' 03 Prescribed by Department of Local Government Finance File Mark
INSTRUCTIONS:
To be filled in person or by mail. Form filed with:
Filing Dates: Form must be completed and dated in the calendar year for which the deduction is sought.
Must be filed or postmarked with the County Auditor or County Recorder of the county where the 0
property is located on or before January 5 of the calendar year in which the property taxes ae first due County Auditor
and payable. ❑ County Recorder
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Patricia Lynne Chamberlain
Taxing District Key number/legal description 26-04-25-101-000.457-020/ rd number Page number
Assessed value of real property as of Mortgage/Contract Indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the ap licant the sole
assessment date,current year assessment date,current year date of application legal o quitable owner?
$46,000.00 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: th roperty in question: Annually Assessed
Iseal Property 0 Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller FILED
Evansville Teachers FederalalCCredit Union
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 MAR ,0 9�,20 �__�G
Address of assignee(number and street,city,state,and ZIP code) Y� GG...G'Yr2�2,` 24
GIBSON SOUNBY.AUOI OR
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been re ues a If yes,state amount of
other county / on property for deduction
in Indiana? 0 Yes [d'No current year? 0 Yes ❑ 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)
6/1A;(1)- / „nt) 4211V ice.;b so h 3/i0I/d•2-
I/We certify under the 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.
Sig a`tur (owner's full name) / Date(month,day,year)
ull resident address of ap scant(number and street,city,state,and ZIP code)
108 S West Mill St., 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.