HomeMy WebLinkAboutMortgage_Gollnick"� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
Slale Farm 43709 (R8 / 2-07)
�' �` Rasaibed by Department of Loral GoVemmart Finance rJ
,•� -n 0
.. �-,��;' er
pill. �' '� < .Fi1
�� � in person or byma3 with the CourttyAuditw o/the courrty where tlie propeRy is bcated. S'��",t�� �'�'� %''��1 ?2���
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Fding Dates: i) Real Property: Dunng the 72 montl�s be%re June 77 W the year the deduction is to 6e e/fective. Ca�' ��t -----� Q ��U� u
2) Mobile Hortres assessed under IC 6-1.7-7: Behveen January 15 and March 2 of fhe year the �ucUon i� edec6ve. ��d.�o�
See reverse side /or additional insWc6ons amd qualifications. �, l 4' �
// •/'l�-: (h: �✓',,�. Couoty
Applicam(amei -see " "ans e) (/ ��lO`��
v
n..�o x
T' DislriQ K mber / legal d 'ption - �d number Page mmiber
6 3 - -DDO •DS6 -�D
psse� vah�e of mal popaty a of Ma 1. a�rari ymr MMgage / ConLatl indebtednass unpaid as of March 1. Is Ihe appfcanl Ihe sole legal or equitahle owneR
aR��� a
❑Yes ❑No
If ro. whal is his / har exad share af itrterest? If owned wilh someone dl�er �han spouse, cWicate with wFiom.
If rmTm record is diHerent Uan lhal of applican4 ����e below: Is 1he propeAy in question:
❑ R�I Property ❑ Mobile Hwr�e QC 61.1
Name of rtwr�gagee or cmL-act selter
Addr¢s ot moAgagee m m�iraci seller (num6er and sLaeC oty, sFafe. arM �a �ode)
Nartre of assignee a olha wvner w hdAer of martgage ' �
Address of azsignee (ixaMer aM sveet dty, sfate. and Z/P oode) ': . _�-
a . Drawer NO........
DoeS applicaN own papertY in arry dher If yes. whal wun .� ��••••••• i been requasted on praperty
caunty in Indiana? '�.j ' ��� � ❑ Yes ❑ No
❑Yes ❑ No � Card N�.
.� .....................
, r ' ^^ �
Deducfbn appmved in Uie amounl oF: . j � t�� Ow ,
2p o 9 2p 2p _ 20 _ 20 _ . 20 _ 20
P
SigreWre of Coun�y AudMr Camly Date (month. daY Y��)
I I We certify under Ihe penalry of perjury that fhe above and foregoing infortnation is true and cortect and tliat the appGpnfs was / were a residenf of
Indiana ar�d owner of the aforemen � ed property on March 1, 20
e' ers name Date (manlh, aaY. Y��
L . .
F ienl a r s of apq� n num6ei and street �, sfate. and ZIP ca�e� ����
�1/V �
Person aWv¢ed Y�+ry ��ted Powa of Altomey or by IC 61.1-12-.07 Date (mmlh. day, yea�
Adtlress ot aulhor¢ed pe�sm (numbe� and streeC cAy. slate, and LP ootle)