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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
-~?°k State Form 43709(R14/1-20) Gibson Union 2022
Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: To be filed in person or by mail. Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. El 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)
Christopher & Emily Cooper
Taxing District Key number/legal description Record number Page number
Union 26-18-03-400-002.480-025 2022 472
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is Is the applicant
antthe
e sole
assessment date,currant year assessment date,current year date of application 9equitable
$350,000 Yes ❑No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
I/name on record Is different than that of applicant,indicate below: Is the pro Try °stlon:Annually Assessed
0 Real r e - nnually Assessed
Mob' Home(IC 6-1.1-7)
•
Name mortgagee or contract seller
Spring Valley Bank ���p
.4)
Address of mortgagee or contract seller(number and street.city,state,and ZIP code) rl J
Name of assignee or other owner or holder of mortgage 2e2
G4BSU� l` tr'rl
Address of assignee(number and street,city,stale,end ZIP code) UNpy�. _ V
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes.sta deduction
other county on n property
EIYes ❑No
in Indiana? ❑Yes ®No y
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)
c� .Ka a. ��a_i--�-V--JJ ,-,. ..(5_ Gibson 3—a1_ ao .
I/ e certify under the penalty of perjury that the above and fo goin formation 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.
Signature(owner's lull name)C Date(month,day,year)
Full resident address of applicant(number and street,city,stele,Ond ZIP code)
5756 S 325 W, Ft. Branch, IN 47648
Person authorized by duly executed Power of Attorney or by IC 5-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city,slate,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
Christopher&Emily Cooper Springs Valley Bank
Date filed month.day,year)^ Amount of indebtedness Taxing District
_ r-P `_ c��a a $350,000 Union
Key number/legal description
26-18-03-400-002.480-025
Signature of County Auditor/CounW, Recorder County ye
ue�c10 D C5a . 1 .- (1-A--k Jribson
`�� MAR 2 1 2022
41 r,, ,-d' f•
.
GIBSON G 'r4't Y AUDITOR