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fiR,� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
� County Township Year
y ; FOR DEDUCTION FROM ASSESSED VALUATION
I
ii, State Form 43709(R13/10-15) Gibson 2019
Rr, Prescribed by Department
county where the property is ■❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought. .
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Rodney& Lisa Jones
Taxing District Key number/legal description Record number Page numbe
Johnson 26-22-12-301-002.123-024 1X0 4o0 t
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?
$235,000 ❑■ Yes El 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 app Is the pro rX iik a on:Annually Assessed
/ — Q O / ', a Real . er Annually Assessed
�-�' 77�� Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Unify Financial Credit Union Drawer NO O� N cLp19
Address of mortgagee or contract seller(nun - C �7 6i
Name of assignee or other owner or holder o Card NO. 94.. O\'(P
• As40- . -c-( "
Address of assignee(number and street,city, G004
\3SGN
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? Yes No current year?CI ❑I
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)
f Gibson 12/26/19
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.
Signature(owner's full name) Date(month,day,year)
12/26/19
Full resident address of applicant(number and street,city,state,and ZIP code)
11534 s 150 w, Haubstadt, IN
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. y =
i�
RECEIPT FOR FILING STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
Name of applicant Name of mortgagee or contract seller w6 Rodney& Lisa Jones Unify Financial Fed Cr Un Derjpi,
Date filed(month,day,year) Amount of indebtedness Taxing District ' 6 2n
12/26/19 $ 235,000 Joinson J
Key number/legal description feSON '
�I
26-22-12-301-002.123-024 COU,.tt, j7
0.
Signature of County Auditor/County Recorder County Date(month;qugar),
> }. kI, Gibson 12/26/19 '-OR