HomeMy WebLinkAboutMortgage_Koberstein (3) r .STATEMENT OF MORTGAGE OR CONTRACT INDEB 1 ' Township Year
,�ic� FOR DEDUCTION FROM ASSESSED VALUATION l
State Form 43709(R13/10-15)
• Presalbed by Department of Local Government Finance
APR 23 File Mark
INSTRUCTIONS:
To be filed in person or by mail. Form filed with:
Filing Dates 1) Real Properly.Must be completed and dated in the calendar year for which the duct
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Must be filed or postmarked with the County Auditor or County Recorder of the..,..:. :. „7►;.` .4` R unty Auditor
located on or before January 5 of the immediately succeeding calendar yegiRSnN COUN gcaCo°unty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file wiM the County Auditor of the county
where the property is located during the twelve(12)months before Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Appli ant( or contra see re on reverse side)
r n `°.
Titrinplistrictaibi Key number/legal description Record number Page number
/1/S Q641 Z. 4 -/ z-/k- 2O / aaz 75'Oo2.R /S /70
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment dal,aarent y�r date of application legal or equitable owner?
cQ 00000 ❑ Yes ❑ No
If no,what is his 1 her exact share of interest? If owned wilh someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate belay. Is the property in question:Annually Assessed
"Ikeal Property ❑ Annually Assessed
• Mobile tome(IC 6-1.1-7)
Name of mortgagee or contract settler S t /') d
Address of mortgagee or contract seller(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
•
Address of assignee(number and street city,state,and ZIP rode) -- - _
Does applicant own property in any If yes,what county? .What Taxing District? Has It Kb 6 E R 5 TEThi .ac VA R —
other county m pry
in Indiana? ❑Yes ❑No surer /,�f(� ��11 _
A person is not entitled to this deduction unless the person has a balance on the person's mom /`' - I'70 8 1(0 y
recorder's office(including any home equity fine of credit that is recorded in the county reoorch - t- - i 7r.y-y7` L �40�
COUNTY AUDITOR
ry�� /VgK'�o,wO 4-15
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor County • Data(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed. n 0
name) / Date(month,L day,3year)a 18
Full address d (numbstr and street city,state,and ZIP code)
>, )q S . cello -N�, 4R✓E4a
Person authorized by duly executed Power of Attorney or by 16 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street may,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.