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-;I I STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
.:::,( FOR DEDUCTION FROM ASSESSED VALUATION
f, �'} State Form 43709(R14/1.20) Gibson 2020
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. m 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)
. Roger B. & Dana W Farmer
Taxing District Key number/legal description Record number Page number
Haubstadt 26-19-31-400-000.462-009 • a 0®� Lk ?.
Assessed value of reel property as of Mortgage/Contract Indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of la the applicant the sale
assessment date,current year assessment date,current year date of application legal or equitable owner?
$30,000 ®Yes ❑No
If no,what is his i her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is ddferent than that of applicant,Indicate below: a property in question:Annually Assessed
eaIPr�.terty ❑AnnuallyAssessed
' Mobile Home(IC&1,1-7)
Name of mortgagee or contract seller r r
5/3 Bank /�/'/ PP
Address of mortgagee or contract seller(number and street,city,state,and ZiP code) "'V t7 Z ®2020
Name of assignee or other owner or holder of mortgage
G/8 'r •
S0N TI/
Address of assignee(number end street city.state,end ZiP code) CODA,
(j
Does applicant own property In any if yes,what county? What Taxing District? Has this deduction been requested If yeasts amount of deduction
other county on erty prop for
in Indiana? ❑Yes ®No current year? Q]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 fine 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
Sig r of County Audito/ wzgrirkis. County Dale(month,day,year)
l m Gibson 8 _ t Q-c _o
I/We certify under the penalty of perjury that the hove foregoing Information is true and correct and that the applicant Is a resident of Indiana and
owner/contract buyer of the aforementioned property on ate application Is filed.
Slgnat owner's tAleme Data(month,day,year)
_ 8- ?- zbz-v
Full resid address of a plicant(number and street,city,state,and ZIP code)
600 E Gibson St., Haubstadt, IN 47639
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 end a fine not to exceed$10,000.
RECEIPT FOR FILING STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE
Name of applicant Name of mortgagee or contract seller
Roger B & Dana W. Farmer 5/3 Bank
Date filed(month,day, ear) Amount of indebtedness —
g-. b3� $30,000rt;--giril...i
utadt Ica)
Key number I legal description r
26-19-31-400-000.462 09 PU I
Sig to a of Au n Couty Auditor/County corder
i� ' County . _{mon%iiyt;.art 40�
hXwl.� Gibson 1,, tr4" 'a`
G�BSON Co
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