HomeMy WebLinkAboutMortgage_Koelling.'°n STATEMENT OF MORTGAGE OR CO�C IN� DI SS Coun 7ownship Year
• FOR DEDUCTION FROM ASSESSE I �J
• State Fortn 43709 (R71 / 609)
�' Pr�aibed by DePa„��n of Wral Gwemmenl Firiance
�"" APR 17 2012 .�t— �_ Fae rna�x
smucnoNS: '
To 6e filed in y ty ry �re tM1e property is located. F� �� �:
persnn w b mail with the Coun Auditor or Coun Recorder-"o
Fifirg Dates: 7) Real Pmperry: Must file during Ne }rear (or which the deduction is so t. County Audimr
2) Mobile / Manufactured Homes not assessed as Real PropeAy Must�i'e�d' eNe (12J months
6efo/eMarch37o/eachyearthedeductionissod�f�SONC0UNT7l� I b� CounryRecorder
See 2verse side fir adtlitional insVUCGOns and qualifications.
AooGranl (ox+re� oribnbaC buyeA � Ru�� m revarse side)
Asse�etl vapie d mal pWMY as ot
Mald� 7. aarenl Year
I( no, what is his! Mr exad share oi interesl?
If riame m mwd ¢ Oifrerent Ihan Nal of app
r / IeBel CesaiPiim Recortl
b—db— I I—! 00 —� • 8�S—O� �
Mortpage / ContraR intlebtedness unpait . s of Morigage / ContrarY irMeMedness unpaid �
Ma�ch 7, wrtent year tlate of appGCation
Addtess M rrortgagce w mntrad se➢er (nunibei and shee4 �'. sfate. aM
Name ot asvgnee w oNU ovmer w holeer ot morigage
AOCress of assignee (number eM apee4 d�Y. �fe, aM
Dces app6mnt pm property in any oNer
counry in IMana?
❑ Yes ❑ No
De�udion appfwed m the amount oE
20 20 � � _ 1
counry! I YJ�a� Tadng D'aGict7
�s
GOUN7YAUDROR
20 _ ( 20 _ I 20
I
Is Ne app�mnl Me sde
legal a eW itable ownM
❑ Yes ❑ No
Is ihe property in Question: Mnua%l�ssrsse0
❑ Real RoPeRY � �!�.Y.�
Has N's deduction Eeen reQUestn
t� �� � ❑ Ye
20 _
— � Dete (montl�. OaY. Y�/1
m prapelly
❑ No
20
� �. _� � �((ia Y� �� � �J.11��
n�-- -- -
-
I/ We certify urder the p nalry of perju th: _ aP I( .,,,... .• �at the appli�ant is a resident of IMiana aM
ownerlmntractbuyeroftheaforementione Dra��'er �0•"""
,qvre ( n ^ �� . . . . . . oate (rnorim. dar, r��
�i 5 �
11 ntaEdressofa I numbeiaM 4 Card tio . ............ • -�-766 U
S .
rson authoraeE Ey duN executed Power of AnomeY . . -' Dace (rtronfh, daY, Y�a�
PddressofaWwf'vedperson (num6eraMShee4�/1Y.���e,eMZlPCatle)