HomeMy WebLinkAboutMortgage_Kiesel (14) cSTATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION �g I $ F
State Fain 43709(R13/10-15) p q
Prescribed by Department of J Local Government Finance I - _IIILLL,�III11000999
INSTRUCTIONS:
File Mark
To be filed in person or by mad. - DEC imr•Tmr1-' -
lang Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought.
Must be filed or postmarked with the CountyAUdifor or County Recorder of the county where the properly is A ❑ County Auditor ,
located on or before January 5 of the immediately succeeding calendar year. •%� ,'
2) Mobile/Manufactured Homes not assessed as Real Property.Must file with the Crum&Auditor of tti�e� r C'' J.' Recorder
where the property is opted during the twelve(12)months before March 31 of each year the deducddA'L.t•.,:. 0 - . : a =
See reverse side for additional instnuXions and qua! ' ns.
(• ,Tl. conact buyer-see� res'nlcr,ansonre sate)descr' ;a- //cJ
6 /0t- 6CS - 66/ J/o - Oa? 2 7877 1 :6
Assessed value threat properly as of Mortgage/Contract indebtedness unpaid as of - Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
rseesnent dale,assent year assessment data,current year date of apprmtion M legal or equitable owner?
&D goo ❑ Yes ❑ No
If no,what is his/her exact sham of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applcant,indicate below: pe property in question:AnmuaflyAssessed
Real PmPer41!tame of mortgagee or contract seller // // ❑ 1.ia)
(mob /p`d/f�//t'.
Address of mortgagee or contract seder(number and street ' ,'stele,a�e)
.
���111777
Name of assignee or other owner or holder of mortgage ' /// /l
Address of assignee(number end street,r>ty,state,and VP code) I / /�
Does applicant own property N any If yr,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other
urdiaannaa? ❑Yes ❑No anent year? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity fine of credit that is recorded in the county recorder's office)that is the basis far the deduction.
COUNTY AUD/TOR " -
Deduction approved in the amount at
•
20 20 20 20 20 I 20 -I 20
Signature of County Austria County //�� /
/We certif y under the penalty of perjury that the above and f D1'a 11'Cf' �ro.. V(l D
ore9cln9' E a and
���t�1` owner t contrail buyer of the aforementioned property on date application is filed. chi,/ C (j
1 ' Sçtrr $ 5 11 `-c�lt� �o. CC Feat address of applicant number and sheet city,stale,and ZIP code) I I //r�� /�
t` 1Iy'4 E T4 4.0 tan �P. Pr:et cejo,+ -NS ^17 70. / f
Person authorized by duly executed Power of Attorney or by IC 6-1.1-1 -0.7 Date(month,day,year)
Address of authorized person (number and street thy,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 310,000.