HomeMy WebLinkAboutMortgage_Kiesel (4)°•� STATEMENT OF MORTGAGE OR CO D SS Coun Township Year
_ ; POR DEDUCTION FROM ASSESSED L 10 ��
' State Fortn 43709IR71 / 609) 1J
�' ,.,. f Presaibed by DepartmeM of Wcal Govemmenl Fnance
��T 11 2��� FiieMark
�srRUCnoNS: F� ��
�0 6e filed in person or by mail vn[h the CountyAUditor or Counry RecordefD/.�0 rre the property is bcated.
FiNrg Dates: 1) Real Property Must file during the year /or which the deduction is so t. Counry Auditor
2) Mobde / ManufaUured Homes not essessed as Real Properfy Must fi u' the tweNe (12) rtwnths
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See reverse side for adddional instrvcGOns arrd qualifcations.
�2f C%2f2 Sh2f8 Of VISP1PSt?
tl na(ne m
Name of rtiortgagee a mntrati
Nlegaltl�,�„ a6-�a-a3--lce-tx�l. �?d'-oa �m I I Pa9e��
pe / a'udehtetlrress unPaid az U Mortgage I ContraG indehtednrss �m7aitl as ot Is Ihe apptlrant the sole
1. ai Cate of aPP�� kgal w epWtade owneR
�OD ❑ Yes ❑ No
tliat of app6caN, cWirate bebw:
Address U rtartgagee m m�trap xAu (numberand sbeel, ctly, smte. aM
Name o1 assynee w oNU owner u halder of mort9aQe..
Addressof� fn=' " � /�\`�,,••••
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If
WhatTaa�g Datrict?
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spouse,
is tlre P�GertY in question: Mm�ally Assessed
❑ Real PioPerty ❑ Armually Assessed
Uiis dedudian Deen reQUested m P�openY
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❑ Yes ❑ No
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I/ We certify under Ihe penally of perjury that Ihe above and foregoing infortnation is We and cortec[ and ihat the applipn[ is a resident of IMiana arM
amer 1 mnhad 6uyer of the aforementioned properry on date appliption is filed.
Inatlue (o�y+�e/s /id name) n �/ ./ � Datelmonfh. daY. Yaa�)
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Puson authorrzed Ey duy exeanetl Pov.�er af Attorney m by
per..on (numDer aiq sIIee4 �'. s+ate.
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Datc (monN, tlzy, yea�