HomeMy WebLinkAboutMortgage_Kiesel (5) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou Township Year
'!' -'-�`` FOR DEDUCTION FROM ASSESSED VALUATION
'�'- State Form 43709 par/10.15) —_
" - Prescribed by Department of Local Government Finance Y�
INSTRUCTIONS: lie File Mark
b be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the AgepRodign is sought ,--,/
Must be filed or postmarked with the County Auditor or County Recorder of the'douRlyMler� property is t� County Auditor
toasted on or before January 5 of the immediately succeeding calendar year ❑ County Recorder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with •unty Auditor of the county
where the is located during the fiche(12)months before 31 .f-?�; _I n: .,:,. :.'n.Is sought
See reverse side for addition sYuctions and qualification . ulaSO vtint
Appecant(ownerorconaa 'f seem on reverse NrnUNTVAUDITOR
T- g .i} Key n leg escriphon Record number Page number
itA(Ca.- as-/ -7-3o-000 7(409 -oav! j 'J /093
Ate--, value of real property as of Mortgage/Contract' ebtedness unpaid as of Mortgage I Contract Indebtedness unpaid as of Is the applicant the sole
assessment data,cement year assessment date, /_�/� date of application legal or equitable owner?
0 O O ❑ Yes ❑ No
If m,what is his/her exact share of interest? 1 If owned with someone other than spouse,indicate with whom
If name on record is afferent than that of applicant,indicate below. Is the property in question:Annually Assessed
❑ Real Properly ❑ Annually Assessed
• Mobile Home(IC 6-11-7)
Name of mortgagee or contract seller \- 1/4—WQ&
Address of mortgagee or contract seller(number and sheet,city,state,and ZIP code)
Name of assignee or other ovmer or holder of mortgage
Address of assignee(number and stmt..-
Does Doer apuppnl .11�/I L5 L 1 g District? Has this deduction been requested If yes,state amount of deduction
in Indiana i 1 1 /� n current R ❑Yes ❑No
A person is �1 r/' DR r on the person's mortgage or contract indebtedness that is recorded in the county
recoders c I _RGV in the county recorder's office)that is the basis for the deduction.
4- ' ! I Tn R INTY AUDITOR
Deduction apt I Uw7J
20_ _ 20 20 20 20 20
Signature of Court for I�,I p_ �. l J County �I Date(month,day.year) .
I t We certify under tthhee/pen/alty`of.`peerrjjuurry that the above an oo information is true and correct and that the applicant is a resident of Indiana and
owner!contract buyer of the aforemention property on date application is filed.
,iolahure(owner's full name) t- 1/4 Data(month,day,year)
' Full resident ad I(Y 1 ! 2 f J / 9c-14._mY95 e5k" d`Lo�P/pi% "'n', ,T/✓• 1176 /2
Person authorized by duty executed Power of Attorney or by IC 6-1.1-40.7 Date(month,day,year)
Address of authorized person (number and street city,state,and LP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000. -