HomeMy WebLinkAboutMortgage_Koberstein (4) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS ______Couriqy I Township I year
1/... lit-i, FOR DEDUCTION FROM ASSESSED VALUATION _2- —7/ State Form 43709(R14/1-23) Gibson 020
027-7
Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: To be filed in person or by mail.
-Form filed with:
Filing Date: Form must be completed and dated in the calendar
1 I County Recorder
_
See reverse side for additional instructions and qualifications_ -
7-Ii Applica .ne. contract buyer ST6ict!arrs orcreverse VI„op:3 vckds---- Acji.J.)
rifaxIMa-IDIStrict Key number I legal descdption I Reco 1 P 4
rd number
nah.gs
Assessed value of real property as of MortgageontraCtindebtedness unpaid as----ci---FIOortg-i,e/Contract indebtedness unraid as of Is the.ap lin nt the so 1
assessment date,current year assessment date current year d, at a ic 'i lega'ore able owner?
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. Yes No
.1 - 0 00
_
1f co.whiatfili'5 i her exact share of interest? I If owned vath ormeone other than-spouise.-M-Cficate wilth whom
is I I
'-if name odrecord is different than that of applicant,indicale boos ---- ------------------' I I ie property in question.Annually Assessed
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. 1 Real Property [II]Annually Assessed
. I Mobile Home(IC 6-1.127)
N a me f rriortOa. act contract sel -.-_
of mortgagee or contract seller)number and street.city state.and ZIP coao)
1 i
TICI-a-hr-Te to assignee or other owner DEC 21 2021 ----------1
Address c7fassg nee(cumber and ,,?() J .....„_._____.___. i
Drawer NO "r}2 , e a...
,----15oeS applicant own property in an s dedt-t-eit-i-O-r-f - n requested-- . .a•- . . unt of deduction —1
,9men,county )erty for r.e.
i in Indiana? rii Yes El Ni
Card NO. ...23.57.S--••
A person is not entitled to this c jage or co t ct indebtedness that is recorded in the county
recorder's office(including any,-,,,,,c,Itnty,ine or credit that is recorded in the county recorder's office) that is the basis for the deduction,
_____
COUNTY AUDITOR i
Deductionapproved in ice amount of
20 1 I 20 I 20_ __ i,
20
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20 _, 0
7„Sigri--atiore f C\\_ourat• A itor i County Dat IT yua
A 1
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I!Vie certify under the penalty of perjuryhat the above and foregoing information is t ue nd correct and that the applicant is a sid4fent Indian A and -I
a on.vner/ ntractibuyer of the aforementioned property on date application is filed._
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Fi.,41-ti sident address of applicant number and stref_t_ cey state,and ZIP,scdV)
tend
A '
c Date(month day year)
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—..
Person authorfZed by duly executed Power of Attorney or by IC 6-111-12-0 7 Date(month.day year)
• _
7----Address of authorized person (number and street city state.and ZIP codeii
rhx nianallies for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000