HomeMy WebLinkAboutMortgage_Kohlmeyer (3)d��> STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
♦�� FOR DEDUCTION FROM ASSESSED VALUATION _
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' Stata Fwm 43709 (Rii / 6-09)
, Prescnbed by Department of Local Govemmeni Finance
File Mark
INSTRUCTIONS:
To 6e filed in person or by maiL Form ned w�m:
Filing Dates: 7J Real Property: Musf be complefed and dated in fhe calendai year lor which the tleduction is souqht.
Musf be filed with the CounryAudifor or Counry Recorder ollhe counry where fhe property is located ❑ Counry Auditor
on or be%re January 5 olfhe immedialely succeeding calendar yeac ❑ Counry Recorder
2) Mo6ile / Manu7actured Homes not assessed as Real PropeRy: Must fiIe with the County Audimr ol the
counry where the pmperty is locafed dunng fhe nveNe (12J monMS before March 31 o/each year the
detlucfion is sought.
See reverse side for addi6onal instrucfions and qualifications.
Applica^I (own¢r w tonfrdct 6uyer- see reshiUions on reverse side)
Jonelle Kohlmeyer
Tapng Distria Key number I 1e9a1 description.� -�_:-;..�_ Record numEer P pp59 3
Ft. Branch Township 26-19-19-103-007214-026�%�LOt 33�in.FartialReplat of.Southgate Sub.
Assessed value W real property as ol Mortgage / Contraci indebtedneu unpaid as of Mortgaga I Con;rad indebtedness unpaid as ot ts Ihe appliwnt Ne sde
Martl� 1, nnrent year March /, wrtent year date of applica;ion legal or equitaWe owna(/
S110,658.00 ❑� Yes ❑ No
If no, what is Itis / �er exaU share of interest? If owned vnN someorre oNer Nan spouu.'uWiw;e wiN whom
IF name on record is dPerent Ihan Nat af apptiwnt, intliwte Gebw Is Na property in Questim: MnuaOy hssassed
❑� Real Pioperry ❑ MnualyASSessed
- Mobile Home QC 61.1-7)
Name of rtartgagee or conVaR se0er
Fifth Third Mortgage Company
Address of mortgagee w conVact se0er (num6er and snee(, ciry. stale, and ZIP cade)
5001 Kingsley Drive, MD: 7MOCBQ. Cincinnati, OH 45227
Name ot assignee or oNer owner or hdder of rtqrt9age
Address of assignee (number antl streeG cify. sfate. and ZIP wLe)
Dces app5`ant own property in any oNer It yes, whal munt�? What Ta�dng DiSVicl7 Has Nis Oeduction been reQuested on property
counry in Ind'ana? for artent yeaR
❑ Yes ❑O No ❑ Yes ❑ No
COUNTY AUDITOR
OeEUCtian apprweE in ihe amounl of:
20 _ 20 20 _ 20 20 _ 20 _ 20 _
Syna;ure of CounryAud'¢or Caunry Date (month. Cay, yee�
I I We certify under ihe penairy of perjury that the above and foregoing infortnatlon is We and wrtec[ and that Ne applicant is a resident of Indiana and
owner / conVact buyer of Ihe aforemenfioned pmperty on date application is filed.
Signat (mme/s fW name // Date ypm Cay, a�
�. .�.,., �� S
F� tlent aCGress ot app4wnt (number C sfreeG dry, state. arMZIP cotle)
09 S. Mdee Ln. , FL Branch, IN 47648
erson authonzetl by tluly executed Paxer of Momey w by IC 61.1-12-0.7 Date (manN. tlay, yea�
Adtlress of autlwr¢ed Derson (number arW sheet �: stafe, ard LP code)