HomeMy WebLinkAboutMortgage_Kiesel (2)^'� STATEMENT OF MORTGAGE OR CONTRACT INDEQ�E�NE� un Township vear
__,_ = FOR DEDUCTION FROM ASSESSED VALUATI� p
• Stata Farm C3709 (R71 ! 6-09) � �.J
� � Presaibed M cePe�rtl af Latal GovemmerLL Fuance
"" Z012 File Mark
�sraucnoNS: pPR 1 0
Fortn i0ed wuh:
To be �led in person oi by mail with the CountyAuditor o� Counry Recorder o! the county wherelh located. jjj���---�����!
FB'vg Dates: i) Real Properry: Must fi!e dunrg the year for which the deductlon is sought. C�'� ����� L�L Counry Auditor
2) Mo6de / Manufactured Homes lrot assessed as Real Property Must file dunng the fwe 1 n
before March 37 of each year the deducfion is so�ght. G�BSON COUNTY AUDIT � U County Retorder
See reverse side !or additioqal instnxGOns end qualifications. -
��^1F'r.?i�����
If ro. what is lus I her e�ma share Ot intemst'�
� �-aa-o3 -/�o-o oo. 53 8-oa - - a- -
Mp� ge / Contract 4debtetlnPSS unpaid az o( Mortgage / Cantraa udeMedness impaid as d �s �he applirant ihe sole
Mamh 1, arteMQ�e rC � data o( aGP�� � O e awrreR
��7 ❑ i�0
tt owneO wi� someone aher ihan spouse. i�dkale wtth whom
m�eco�tl's 6tferent Nan Nat al aPpfMant,
rlame ot rtartg�ee « m�vaa une�
Addres af mort9a9ce or contrad se�e
Nama of asvgnee or other owne
Aildress of assignce (nurt�6er arM.
Oces appliraM wm poperty in any c
munry in Intlana? ❑ Yes
1
�
p¢Euction app�oved'o� tlre amoum ot
20 20 _
� � _"� , IQIC�
1 I We certi(y under �he penalry
i owner / mntract buyer of Ihe a
���-aoi�
�, i
�Ya���Y rO. .,..
sp. )(u(p u
CaYd�' � �� �
�3 ,
Ppfson auW`rzetl by EWy executed Powr! of
2Q _
(numOeraMStreet tlf}: sfate.
COUNTY
20
/
What Ta�dng Distridl
AUDROR
I 2(1
Is C�e P�rtY in VuesGan: AnnueM Assessed
❑ Rea� Property ❑ amua�y Assesud
Mohle Flon� (IC 61.
requesLLd on pf W erty
❑ Yes ❑
2p_ � 20
Date (rrrornn.
and foregoing infortnalion is W e and mrtect arM tha[ fhe applirant is a resident of Indiana aM
n da[e application is filed.
Date (rtonth, daY. Y�a�)
Z/POOtle)
�
Date (rtronN, day, yea�