HomeMy WebLinkAboutMortgage_Kohlmeyer (2)"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS C Tow 'p vear
__ . FOR DEDUCTION FROM ASSESSED VALUATION
� State Fortn A3709 (R11 / 609)
S,,,. , Presaibee by Department of Laal Govemment Fi�nce d.
ile
�NSTRUCTIONS: C.'� --
To 6e lled in y n, Fofii4pe
person a 6y mail wifh the CounryAUdita or Coun Recorder of the ooun where the property is located. `��
FiNrg Dates: 7) Real Pioperry: Mus! file durng the year tor which the deduction is so�ght GIB pN unry Audhor
2) Mo6de /Manufactured Homes not assessed as Real Property Musf h7e dunng the hveHe (12J mon�s C U �
before March 37 0! each year the deduction is sought. lae��
See reverse side for addiLOnal insfi�cUons and qualificafions.
Aoofi�nt (owrreroroonhaC 6wer- see re.sbictiuws m reverse stlel , i � _
Tatirg DiStrrcY �
�������
A1a��'h 1, anpni y�x
If ro, what a ha ! her e�G shara ol
If name m remrE is Eifte�mt Nan ft
Name of rmtoaoee ar oontsrl sell�
ia-z5- �o3bl`�'`I aco9 5� S
ga9e 1 Contraa intle6teCness unpaiC as W Mortgage I ContraR cWebtednvs5 unpaiE as of Is the appfra�rt Ihe stle
3� t, arrent yrar date o( appGolion legal a epuitade ow+�ef.+
I I �i �I L� d ❑ Yes ❑ No
u�difate bebvi:
Adtlress W rtnrtgagce ar mntraa seller (nurtiber and sbee; ciry, state, aM ZIP coda)
Name
Dces apptita(u wm D�G�Y in any aher
tou�LLyinlnd'ana?
_ ❑ Yes
2Q 20
�
SignaNre I Counry Audiior
I( avmed wiN someone other Ihan spouse. udirate with wtnm
mortgage
stafe, an0 ZIP ootle) l
If yes. what mum7R
� No �
— — COUNTYAI
,I�s property in qurstion: Mnuaaj AssesseE
�Xl Kfa� P'°aenv ❑ amua�y assessed
. C/���� ••••'•.
{� �` �O 5�� 5 .
Vt�", ,•
Ca,���• "��j �n �
�``� �o�. -
20 � 20 � 20
Counry
n property
❑ No
2(1 I 20
aay
I/ We certify u�er the penalry o( perjury that the above and (oregoing in(ortna�on is We and corted and Na[ ihe applipnt is a resident of IrWiana aM
owner I wntract buyer of the atorementioneA property on date applicalion is filed.
Inam�4[qlmeh�u0nertrel / / �% Date(imnfh.daY.Weh
state, antl
or by IC 61.1-12�]
AtlCress of autlror¢etl pnlson (number arM streef, dry, sble, ard ZIP mde)
Date (monfh. tlaY, Y��