HomeMy WebLinkAboutMortgage_Kiesel (5)FORM 5
.•�•n< STATEMENT OF MORTGAGE OR CONTRACT Filin fee $1.00
'� � p` INDEBTEDNESS FOR DEDUCTION FROM ASSESS
y Co n wnship Year
'' VALUATION State Form 43709.(1-90) Prescribed by ��
�• � State Board of Tax Commissioners �
� AU
Instructions for filing: Fil Mark
To be filed in person or by mail with the County Auditor of the county w
property is located during the 12 months before May 11 of the year the (CWBa6hl COUNTY AUDITOR
is to be effective. See reverse for additionat instructions and qualifications.
or contract
T
see
<ey Num6er/Legal Des
� 7-bna�
Record No.
�
+� ... .
�
Assessed value of real property as Mortgage/Contract Indebtedriess unpaid Is the applicant the sole legal or
of March 1, current year as of �h 1, current year. equitable owner? O yes O no
�
If no, what is his/her ezact share or interest? � � If owned with someone other tlian spouse,
� indicate with whom.
If name on record is different than that of applicant, indicate below:
�-�e of mortgagee or contract sE
Address of mortgagee or contract
Name of Assignee or other owner or holder of Mortgage.
of Assignee
,
%L/' D���/�! •-
Does applicant own !eai property If yes, what county? What Taxing District? Has this deduction been
in any other county in Indiana? requested on property for current
year? O yes O no
COUNTY BOARD OF REVIEW ACTION
Deduction approved in the amount of:
Year _Q� I Yea� � °�
�/2-0
Signature � a
Year U.9 � Year �`'� � Year
Year v � I Year
Secretary of Board of Review � Date
�P P I
I/We certify under penatty of perjury that the above and foregoing information is true and correct and that the
�licants was/were a resident of Indiana and owner of the aforementioned property on March 1,
full
Person authorized by duly executed Power of Attorney or
by IC 6-1.1-12-.07).
Address of Tpplicant , _ I Address of Authorized Person