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�En,�.�, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
of �t:_ FOR DEDUCTION FROM ASSESSED VALUATION
}'�r `1 State Form 43709(R14/1-20) Gson 021 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. Ii 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
534
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?
177,000 11Yes ❑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
®Real Property ❑Annually Assessed
FILED
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract selleETFCU
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) `(�
Name of assignee or other owner or holder of mortgage D`C O 6 202�) �.
Address of assignee(number and street,city,state,and ZIP code) L6
Does applicant own property in any If yes,what county? What Taxing District? Has this deductionbb� t�'If7 •� ' 0 of deduction
other county ❑ ❑ p P rty vor ®Yes ❑No R
in Indiana? Yes No ocurrent year.
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 o CoV ty Auditor �'k" r� County Date(month,day,year)
/uV G� Gson Ia./ /7?
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.
)( Signa (owner's full name Date(month,day year)
\ re j (9,.,1. et 1:)..}' . �,. // - / 9 -cQ•Q
u I res ent address of appli ant(number and street,city,s ,anu /P code)
6745 W 400 S, O'ville,IN 47665
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
Harrell, Lisa D/Merle Pfeil II ETFCU
Date filed(„7 .. r)-� Amount of indebtedness Taxing District
/ !!!//// 177,000 021
Key num er/legal description
26-10-36-200-003.807-021
Signature f ounty uditor/Counn Rjcordd�er Q, - County Date(month,day,year)
l�v Gson /C4/s7