HomeMy WebLinkAboutMortgage_Kiesel (2)"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBT�� o Townsnip Year
:.,_- .
� FOR DEDUCTION FROM ASSESSED VALUATION
:• Sfate Fortn 43709 (R71 / 6-09)
ti,�,� � P�esaibetl q' DePaRmeM of Lomi GovemmeM Financa
�STRUCTIONS: NQV
2 �1 20�� File Mark
be �led in Y �y ry ry Form f�ed wi�h:
person or b maii wiN the Coun Auditor or Coun Recorder o/ Me ooun where the � isleea .
Filirg Dates: 7J Real Pmperty: Must file dunng fhe year (or which fha deduttion is soughL C� Counry Auditnr
2) Mo6i7e / ManuFactured Homes not assessed as Real Praperly Must file during the Iwelve (12J
before March 37 of each year the deduclion is soughL Counry Recorder
See reverse side for additional inshuctinns and qual�cations.
�,�gSON COUNTY AUDITO
AnaGnm(o�vnerormntractbuver-searestnrJiens reversesidel n
pmperty as of
11 name m remd's QMe�ent than ihaf N aPP�t "mtlipte bebw
�� � ��
� .,
w contrac� se0er (nurtNe� and sbee; tiry, stae. aM ZfP codel "- -'
Name o( assi�ee w wtmr owner
AAtl255 of assignee (numberaM atree4 �1: slate, and ZIP cotle)
Does e�imnt own poperty in any oNer If yes, what munryR
munrymlrWaria? ❑ Yes
❑ No
DetlucOm approved in �he amouni of:
20 � 20 _
Signa4ve of Camry Auditor
sorneo�
unpai0 as M is Ne appGCant Ne sde
legal w equBade ovrtreY?
❑ Yes ❑ No
property in puestion: MnuaOy As5e55eE
ea�Roperty ❑,Mnuallyass�d
r�ow� r� nc s
DI'�11'Cl' 1�'�.....O�OI I
.....
����� �.io. ..... � 5a� ��P�
b`! � ���.UU ........ re� ❑ No
20 � 20 _ � 20 � 20 _ � 20
I/ We certify urWer the penalty of peryury Mat Ne above arW (wegning infomialion is We and correct a� that Ihe appliranl is a resident of IMiana aM
owner / mntracl buyer of ihe aforemen�ioneG property on da[e applicatlon is filed.
Siprenue(ownelst�reme) ,/ � /
�7/l+�
FWI resident addrass of appGrant (num6
� �-, e rn e
tlry, stare, antl
of autharzed person (numberamd stree; cky, stafe, antl ZIP code)
Daie (rtmtl�. daY. Yaar)
oa�e ��w. e�y ,ean